INFORMATION FOR PEDIATRIC UROLOGY ASSOCIATES, P.C.
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR HEALTH INFORMATION
PLEASE REVIEW THIS NOTICE CAREFULLY
OUR COMMITMENT TO YOUR PRIVACY
We are required by law to maintain the confidentiality of your health information, Protected Health Information (PHI), and to provide you with this notice of our legal duties and privacy practices. We are also required to abide by the terms of this notice. We reserve the right to revise or amend these terms and any revisions will be effective for all of your medical records we maintain. A copy of a revised notice will be available at all our offices or by contacting our Privacy Coordinator. You may also address questions regarding privacy practices, your privacy rights, or request for additional information regarding your privacy to our Office Manager at each location or our Privacy Coordinator at the following:
Pediatric Urology Associates, P.C.
334 Underhill Ave., Building 3-C
Yorktown Heights, NY 10598
Attn: Privacy Officer
USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
Your PHI may be used and disclosed by your doctor, our office staff and others outside of our office that are involved in your care and treatment, to obtain payment for services provided to you, to support the operation of the practice and any other uses required by federal, state or local law. You have the right to review this Notice before signing the consent authorizing use and disclosure of your PHI for treatment, payment and health care purposes.
Treatment. We will use and disclose PHI to provide, coordinate, or manage your health care and any related services; for example, to diagnose and treat your illness or injury, to write a prescription, or to contact you to provide appointment reminders. Our practice may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you or to inform you of potential treatment options or alternatives. We may also disclose PHI to other providers involved in your treatment or disclose PHI to others who may assist in your care, such as your spouse, children or parents.
Payment. We may use and disclose your PHI in order to obtain payment for the services you receive from us or to confirm your coverage. For example, we may contact your health insurer to certify that you are eligible for 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.
Health Care Operations. Our practice may use and disclose your PHI to operate our business. For example, our practice may use your PHI to evaluate the quality of care you received from our physicians and other health care providers or to conduct cost-management and business planning activities for our practice. We may also disclose PHI to our office manager in order to resolve any complaints you may have and ensure that you have a pleasant visit with us.
YOUR RIGHTS REGARDING YOUR PHI
Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to receive PHI by alternative means of communication or at alternative locations.
Requesting Restrictions. You may request a restriction in our use or disclosure of your PHI for treatment, payment, and other health care operations or to individuals (such as family members or any other person identified by you). We are not required to agree to your request; however, if we do agree, we will abide by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. Your request must be: 1) in writing, 2) describe the information you want restricted, 3) state if the restriction is to limit our use or disclosure, and 4) state to whom the restriction applies. If you wish to request restrictions, you may obtain a request form from our Privacy Coordinator or Office Manager and submit the completed form to either the Office Manager or Privacy Coordinator. We will send you a written response.
Inspection and Copies. You may request to inspect and obtain a copy of your PHI, including patient medical records and billing records. All requests for access must be in writing. Under limited circumstances, we may deny you access to your records. If you desire access to your records, you may obtain a request form from the Office Manager or Privacy Coordinator and submit the completed form to either the Office Manager or Privacy Coordinator. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request.
You should take note that, if you are a parent or legal guardian of a minor, certain portions of the minor’s medical record will not be accessible to you (for example, records relating to venereal disease, abortion, or care and treatment of which the minor is permitted to consent himself/herself such as HIV testing, sexually transmitted disease diagnosis and treatment, chemical dependence treatment, prenatal care, care received by a married minor, and contraception and/or family planning services).
Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete. Your request must be in writing and include a reason to support the amendment. You may obtain an amendment request form from our Privacy Coordinator or Office Manager and submit the completed form to either an Office Manager or Privacy Coordinator. We will comply with the request unless you fail to submit your request (and the reason supporting your request) in writing, or we believe the information is accurate and complete, or other special circumstances apply.
Accounting of Disclosures. You have the right to request an accounting of certain disclosures of PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, we will charge you for the accounting statement. Our practice will notify you of the costs involved with additional requests and you may withdraw your request before you incur any costs.
Right to a Printed Copy of This Notice. You are entitled to receive a paper copy of our Notice of Privacy Practices by making a request at our office.
Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint directly with us using the contract information above or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint either to us directly or with the Secretary.
Right to Provide an Authorization for Other Uses and Disclosures. We will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. You may revoke your authorization at any time in writing.
USE AND DISCLOSURE OF YOUR PHI WITHOUT YOUR WRITTEN AUTHORIZATION
Notification. Unless you object, we may use or disclose your PHI to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.
Communication with Family. We may use or disclose to a family member, other relative or close personal friend or any other person identified by you, PHI relevant to that person’s involvement in your care or in payment for such care. If you object to such uses or disclosures, please notify the Office Manager.
Public Health Risks. Your PHI may be disclosed to public health authorities, such as the FDA, as required by law, for the purposes of preventing and controlling disease, injury, or disability.
Victims of Abuse, Neglect or Domestic Violence. If we reasonably believe you are a victim of abuse, neglect or domestic violence, we may disclose PHI to public authorities, authorized by law to receive reports of such abuse, neglect, or domestic violence.
Health Oversight Activities. We may disclose your PHI to a health oversight agency that oversees the healthcare system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare and Medicaid.
Judicial and Administrative Proceedings. We may disclose PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
Law Enforcement. We may disclose PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.
Deceased Patients. We may release PHI to a medical examiner or coroner as required by law.
Organ and Tissue Donation. We may release your PHI to organizations that handle organ, eye or tissue procurement banking or transplantation.
Research. We may use and disclose your PHI if an Institutional Review Board/ Privacy Board approves a waiver of authorization for disclosure.
Health or Safety. We may use and disclose PHI to reduce or prevent a serious and imminent threat to a person’s or the public’s health or safety.
Specialized Government Functions. We may disclose your PHI to units of the government with special functions, such as the U.S. Military or the U.S Department of State as required by law.
Workers’ Compensation. We may release your PHI for workers’ compensation and similar programs.
As required by law. We may use and disclose PHI when required to do so by any other law not already referred to in the preceding categories.
Website. We maintain a website that provides information about our practice. This Notice will be on the website.
Effective date This Notice is effective on April 14, 2003