Below is our notice of privacy to our patients as mandated by new HIPAA federal regulations. Please read this document and be prepared to receive this document in the office along with the Aknowledgement of Receipt. As much of this material is new to you it would be helpful to read this in advance.

PEDIATRIC SPECIALISTS OF FOXBOROUGH & WRENTHAM

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

PLEASE REVIEW THIS NOTICE CAREFULLY.

A. OUR COMMITMENT TO YOUR PRIVACY

Our practice is dedicated to maintaining the privacy of your protected health information (PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. 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 PHI. 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 PHI

•  Your privacy rights in regard to your PHI

•  Our obligations concerning the use and disclosure of your PHI

The terms of this notice apply to all records containing your PHI 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 records that our practice has created or maintained in the past, and for any of your 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. It will also be available on our website at www.pediatricspec.com.

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

Pediatric Specialists

132 Central St.

Foxborough, MA 02035

508-543-6306

C. WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION (PHI) IN THE FOLLOWING WAYS (The following categories describe the different ways in which we may use and disclose your PHI.)

1. Treatment . Our practice may use your PHI to treat you. For example, we may ask you 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 PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children or parents.

2. Payment . Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items.

3. Health Care Operations . Our practice may use and disclose your PHI 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 PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice.

4. Appointment Reminders . Our practice may use and disclose your PHI to contact you and remind you of an appointment.

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

6. Health-Related Benefits and Services . Our practice may use and disclose your PHI 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 PHI to a friend or family member that is involved in your 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 PHI when we are required to do so by federal, state or local law.

D. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES

(The following categories describe unique scenarios in which we may use or disclose your identifiable health information.)

1. Public Health Risks . Our practice may disclose your PHI 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 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 patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information

•  notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

2. Health Oversight Activities . Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and 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 PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

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

•  Regarding a crime victim in certain situations, if we are unable to obtain 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)

5. Deceased Patients . Our practice may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.

6. Organ and Tissue Donation . Our practice may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.

7. Research . Our practice may use and disclose your PHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your PHI for research purposes except when : (a) our use or disclosure was approved by an Institutional Review Board or a Privacy Board; (b) we obtain the oral or written agreement of a researcher that ( i ) the information being sought is necessary for the research study; (ii) the use or disclosure of your PHI is being used only for the research and (iii) the researcher will not remove any of your PHI from our practice; or (c) the PHI sought by the researcher only relates to decedents and the researcher agrees either orally or in writing that the use or disclosure is necessary for the research and, if we request it, to provide us with proof of death prior to access to the PHI of the decedents.

8. Serious Threats to Health or Safety . Our practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your 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.

•  Military . Our practice may disclose your PHI if you are a member of U.S. or foreign

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

10. National Security . Our practice may disclose your PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

11. Inmates . Our practice may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.   

12. Workers’ Compensation . Our practice may release your PHI for workers’ compensation and similar programs.

E. YOUR RIGHTS REGARDING YOUR PHI (You have the following rights regarding the PHI that we maintain about you.)

1. Confidential Communications . You have the right to request that our practice communicate with you about your 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 Pediatric Specialists, 132 Central St., Foxboro, MA 02035 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. Requesting Restrictions . You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI 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 you. In order to request a restriction in our use or disclosure of your IIHI, you must make your request in writing to Pediatric Specialists, 132 Central St., Foxboro, MA 02035, 508-543-6306 . Your request must describe in a clear and concise fashion:

•  the information you wish restricted;

•  whether you are requesting to limit our practice’s use, disclosure or both; and

•  to whom you want the limits to apply.

3. Inspection and Copies . You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Pediatric Specialists, 132 Central St., Foxboro, MA 02035, 508-543-6306 in order to inspect and/or obtain a copy of your PHI. Our practice may charge a fee 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 reviews.

4. Amendment . You may ask us to amend your 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 Pediatric Specialists, 132 Central St., Foxboro, MA 02035, 508-543-6306 . 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 PHI kept by or for the practice; (c) not part of the PHI 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 PHI for non-treatment or operations purposes. Use of your PHI as part of the routine patient care in our practice is not required to be documented. For example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to Pediatric Specialists, 132 Central St., Foxboro, MA 02035, 508-543-6306 . All requests for an “accounting of disclosures” must state a time period, which may not 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 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. To obtain a paper copy of this notice, contact Pediatric Specialists, 132 Central St., Foxboro, MA 02035, 508-543-6306 .

7. Right to File a Complaint . If you believe your 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 Pediatric Specialists, 132 Central St., Foxboro, MA 02035, 508-543-6306 . 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 PHI may be revoked at any time in writing . After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note, we are required to retain records of your care.

E.OTHER AMENDMENTS REGARDING YOUR PHI:

1.Inter-office transportation of your medical records/PHI. Because Pediatric Specialists maintains two distinct physical offices separated by some distance there may arise an occasion to hand carry medical charts, reports etc between the two offices. We make every effort to maintain our commitment of confidentiality during the span of time this information is outside the physical confines of our two offices.

2.Phone messages. During the course of the day it may become necessary to contact you. We may call you at any of the phone numbers you have provided to us, unless specifically stated by you in writing. We make every effort to maintain our commitment of confidentiality when calling you at the workplace or when leaving messages/voicemails (at home or work).

3. Disclosing Information for Payment: If you restrict disclosing information for payment (you’ve asked us to NOT bill insurance for a service), we will ask you to sign an agreement indicating that you are originating the request, that you will be liable for payment for all such services requested at our full charge rate, and that you will not ask your insurance carrier to pay for such services or to appeal to our Practice. In the event that you contact your insurance carrier about such services, either to ask the carrier to pay or to complain that the Practice has asked for payment for a covered service(such as an office visit), we may disclose to the carrier the fact that you had agreed to a waiver to pay for services, that you had requested us not to bill or otherwise contact your carrier, and may have to disclose the reason for the visit, such as the diagnosis or procedure.

4. Coverage office visits: As we share weekend/holiday coverage of our offices with the offices of Pediatric Associates of Norwood & Franklin, and because both practices are trained and comply with HIPAA regulations as mandated by federal law, all portions of our “Notice of Privacy Practices” shall apply to coverage patients and their Privacy Practices Policy shall apply to our patients.

Again, if you have any questions regarding this notice or our health information privacy policies, please contact Pediatric Specialists, 132 Central St., Foxboro, MA 02035, 508-543-6306 .

              02/2003

PEDIATRIC SPECIALISTS OF FOXBOROUGH & WRENTHAM

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

Note: In this notice, “you” and “your” are also used to mean and pertain to “your child.”

I have been given a copy of the Pediatric Specialists Privacy Policy which explains in detail how my

health care information is used and shared with others. The Policy explains (1) when I need to give

further approval for the providers to use my health information or share it outside the practice and

(2) when my permission is not needed for the providers to use my health information or share it outside

the practice (e.g. required by law, public health activities, etc.)

I understand that Pediatric Specialists has reserved the right to change the Privacy Policy at any time.

I may obtain a current copy of the Privacy Notice by request when I am in the office or by contacting

the Privacy Officer.

This acknowledgement covers the following child/children:

_________________________________________     ____________________________________

_________________________________________     ____________________________________

_________________________________________     ____________________________________

My signature below constitutes my acknowledgement that I have been provided a copy of the

Privacy Policy.

__________________________________________     __________________________

Signature of Patient (if over the age of 18) or parent/guardian     Date

__________________________________________

Name (Print)

If you decide not to sign, we are permitted to use a signature by one of our employees as proof

that you have received our POLICY.

__________________________________________     ___________________________

Signature of Pediatric Specialists Employee           Date

                    02/2003