Pediatric Services of America Notice of Privacy Practices

Effective 1/03/03

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.

Pediatric Services of America uses health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive. Your health information is contained in a medical record that is the physical property of Pediatric Services of America.

How Pediatric Services of America May Use or Disclose Your Health Information

For Treatment. Pediatric Services of America may use your health information to provide you with medical treatment or services. For example, information obtained by a health care provider, such as a physician, nurse, or other person providing health services to you, will record information in your record that is related to your treatment. This information is necessary for health care providers to determine what treatment you should receive. Healthcare providers will also record actions taken by them in the course of your treatment and note how you respond to the actions.

For Payment. Pediatric Services of America may use and disclose your health information to others for purposes of receiving payment for treatment and services that you receive. For example, a bill may be sent to you or a third-party payor, such as an insurance company or health plan. The information on the bill may contain information that identifies you, your diagnosis, and treatment or supplies used in the course of treatment.

For Health Care Operations . Pediatric Services of America may use and disclose health information about you for operational purposes. For example, your health information may be disclosed to members of the medical staff, risk or quality improvement personnel, and others to:

1. Evaluate the performance of your staff;

2. Assess the quality of care and outcomes in your cases and similar cases;

3. Learn how to improve our facilities and services; and

4. Determine how to continually improve the quality and effectiveness of the health care we provide.

Appointments. Pediatric Services of America may use your information to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to the individual.

Fund Raising. Pediatric Services of America may use your information to contact you to raise funds for Pediatric Services of America; or a group health plan, health insurance issuer, or HMO with respect to a group health plan may disclose information to the sponsor of the plan.

Required by Law . Pediatric Services of America may use and disclose information about you as required by law. For example, Pediatric Services of America may disclose information for the following purposes:

1. For judicial and administrative proceedings pursuant to legal authority;

2. To report information related to victims of abuse, neglect or domestic violence; and

3. To assist law enforcement officials in their law enforcement duties;

Public Health. Your health information may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability, or for other health oversight activities.

Decedents. Health Information may be disclosed to funeral directors or coroners to enable them to carry out their lawful duties.

Organ/Tissue Donation . Your health information may be used or disclosed for cadaveric organ, eye or tissue donation purposes.

Research . Pediatric Services of America may use your health information for research purposes when an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approve the research.

Health and Safety. Your health information may be disclosed to avert a serious threat to the health or safety of you or any other person pursuant to applicable law.

Government Functions. Specialized government functions such as protection of public officials or reporting to various branches of the armed services that may require use or disclosure of your health information.

Workers Compensation. Your health information may be used or disclosed in order to comply with laws and regulations related to Workers Compensation.

Your Health Information Rights

Your have the right to:

1. Request a restriction on certain uses and disclosures or your information as provided by 45CFR§164.522; however, Pediatric Services of America is not required to agree to a requested restriction;

2. Obtain a paper copy of the notice of information practices upon request;

3. Inspect and obtain a copy of your health record as provided for in 45 CFR§164.524;

4. Amend your health record as provided in 45CFR§164.426;

5. Request communications of your health information by alternative means or at alternative locations;

6. Revoke your authorization to use or disclose health information except to the extent that action has already been taken; and

7. Receive an accounting of disclosures made of your health information as provided by 45CFR§164.528.

Complaints

You may complain to Pediatric Services of America and to the Department of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against for filing a complaint.

Obligations of Pediatric Services of America

Pediatric Services of America is required to:

1. Maintain the privacy of protected health information;

2. Provide you with this notice of its legal duties and privacy practices with respect to your health information;

3. Abide by the terms of this notice;

4. Notify you if we are unable to agree to a requested restriction on how your information is used or disclosed;

5. Accommodate reasonable requests you may make to communicate health information by alternative means or at alternative locations; and

6. Obtain your written authorization to use or disclose your health information for reasons other than those listed above and permitted under law.

Pediatric Services of America reserves the right to change its information practices and to make the new provisions effective for all protected health information it maintains. Revised notices will be made available to you by written notification.

Contact Information

If you have any questions or complaints, please contact:
Privacy Officer General Counsel
1-800-950-1580 1-800-950-1580