Notice of Privacy Practices

Cleveland Pediatrics, P.C.

Notice of Privacy Practices

This Notice describes how protected medical information about you may be used and disclosed and how you can gain access to this information. Please review it carefully.

1. Cleveland Pediatrics, PC is permitted make use and disclosures of protected health information for treatment, payment and health care operations, as described in the following examples:
2. For treatment – PROVIDING INFORMATION TO A SPECIALIST WE HAVE REFERRED YOU TO.
3. For payment—SENDING OR RESPONDING WITH YOUR HEALTH INSURANCE CARRIER
4. For health care operations – OPERATIONS REVIEW: MEDICAL, LEGAL, FRAUD & ABUSE.
5. Cleveland Pediatrics, PC is permitted or required, under specific circumstances, to use or disclose protected health information without the individual’s written authorization.
6. Other uses and disclosures will be made only with the individual’s written authorization, and the individual may revoke such authorization.
7. Cleveland Pediatrics, PC intends to engage in (1) one or more of the following activities:
8. Cleveland Pediatrics, PC may contact the individual to provide appointment reminders or information about treatment alternatives or other health-related benefits or services that may of interest to the individual or patient.
9. Cleveland Pediatrics, PC may contact the individual to serve as source of data for medical research.
10. Cleveland Pediatrics, PC may contact the individual to serve as source of information for public health officials charged with improving the health of the nation.
11. The individual has the following rights regarding protected health information:
12. The right to request restrictions on certain uses and disclosures of protected health information. Cleveland Pediatrics, PC is not required to agree to a requested restriction, however.
13. The right to receive confidential communications of protected health information, as applicable.
14. The right to inspect and copy protected health information, as provided by the Privacy Regulation 45 CFR 1664.524.
15. The right to amend protected health information, as provided in the Privacy Regulation 45 CFR 1664.528.
16. The right to receive and accounting of disclosures of protected health information.
17. The right to obtain a paper copy of this Notice from the covered entity upon request. The right extends to an individual who has agreed to receive the Notice electronically.
18. The right to restrict disclosure of PHI to a health plan if the disclosure is for payment or health care operations AND pertains to a healthcare item or service for which the patient has paid out of pocket in full.
19. The right to receive electronic copies of PHI for the PHI that is maintained by the practice electronically, either in the electronic form or in a format requested by the patient (if such format is readily producible). If the requested format is not readily available, Cleveland Pediatrics, PC must offer at least one readable electronic format. If the patient and practice cannot agree on a format, a readable hard copy of the record must be provided. Cleveland Pediatrics is not required to purchase software or hardware to accommodate patients’ requests.
20. A right to (or will receive) notifications when there has been a breach of unsecured PHI.
21. Cleveland Pediatrics, PC is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and Privacy practices with respected to protected health information.
22. Cleveland Pediatrics, PC is required to abide by the terms of the Notice currently in effect.
23. Cleveland Pediatrics, PC reserves the right to change the terms of this Notice. The new Notice provisions will be effective for all protected health information that it maintains.
24. Cleveland Pediatrics, PC will provide individual or patients with a revised Notice by MAIL OR DISTRIBUTION AT THE NEXT VISIT AFTER REVISIONS.
25. Individuals may complain to Cleveland Pediatrics, PC and to the Secretary of the Department of Health and Human Services, without fear of retaliation by the organization, if they believe their privacy rights have been violated. A brief description of how the individual may file a complaint follows: IN WRITING, OUTLINING THE SOURCE, DATE AND REASON.
26. Cleveland Pediatrics, PC’s contact person for matters relating to complaints is:
27. Robin Davis, CMOM, CMPM

     Practice Administrator

1. (423) 479-9733
2. 435 25^th Street NW
3. Cleveland, TN 37311

 This Notice is first in effect on April 14, 2003.

 Cleveland Pediatrics, PC elects to limit the uses or disclosures that it is permitted to make as follows: We will not disclose your health information without your authorization, except as described in this Notice.