"What is your statement concerning my privacy?"

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU

MAY BE USED AND DISCLOSED AND HOW YOU CAN

GAIN ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

Our mission is to partner with you to achieve optimum health for your child.  By making it a priority to establish an open, cooperative relationship with our patients and their family, we will provide individual, resourceful and beneficial medical care.  Through these activities, the Center for Pediatric and Adolescent Medicine (CPA Med) collects, uses, and discloses protected health information to carry out its mission.  This information is private and confidential.  We have established policies and procedures to protect the information against unlawful use and disclosure.  This notice will provide you with important information, including how to contact us with questions about this notice or our privacy practices and procedures.

This notice describes information we collect, how we use that information, and when and to whom we may disclose it.   It is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Protected health information or “PHI” (also called “personal health information”), is current, past or future information created or received by the Center for Pediatric and Adolescent Medicine through its health care providers and business associates.  It relates to the physical or mental condition of a patient, the provision of health care to that person, or payment for the provision of health care to that person.

The Center for Pediatric and Adolescent Medicine 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 your child or children.  We are required by law to maintain the confidentiality of health information that identifies you and your child or children.  We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain at the Center for Pediatric and Adolescent Medicine concerning your PHI.  By federal and North Carolina law, we must follow the terms of the Notice of Privacy Practices that we have in effect.

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 the Center for Pediatric and Adolescent Medicine.  We reserve the right to revise or amend this notice at any time.   Any revision or amendment to this notice will be effective for all of your records that we have created or maintained in the past, and for any of your records that we may create or maintain in the future.  We will post a copy of our current notice in each of our offices and on our web site www.cpamed.com.  You may request a paper copy at any time.

Treatment, Payment and Health Care Operations (TPO)

We may use or disclose PHI with or without your consent to provide health care services.  Examples of these uses and disclosures include:

§    Treatment.  The Center for Pediatric and Adolescent Medicine may use or disclose your PHI for your treatment and to provide you with treatment-related health care services.  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 the Center for Pediatric and Adolescent Medicine, 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.

§    Payment.  The Center for Pediatric and Adolescent Medicine 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.

§    Health Care Operations.  The Center for Pediatric and Adolescent Medicine will use and disclose your health information to conduct the business activities of this office. These activities include, but are not limited to, quality assessment and improvement activities, review of the performance and qualifications of employees, evaluating provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Other examples of operational actions include, but not limited to, calling you by name in the waiting room when we are ready to begin your treatment, transferring information should you obtain care at our satellite office, or sharing protected health information with business associates that perform specific functions for our practice such as billing, collections, software updates, and lab analysis.  When a business arrangement of this type requires the use of your information, we will have a written contract with the third party to protect the privacy of your protected health information.

Other Activities Permitted or Required by Law

We may use or disclose PHI for other important activities permitted or required by law, with or without your authorization.  These include:

§    Appointment Reminders and Treatment Alternatives.  The Center for Pediatric and Adolescent Medicine may use and disclose your PHI to provide appointment reminders or information concerning potential treatment options or alternatives or other health-related benefits or services that may be of interest.

§    Public Health.  The Center for Pediatric and Adolescent Medicine may disclose your protected health information for public health activities and purposes to the Department of Health and Human Services or other local health agencies that is permitted by law to collect or receive the vital statistical information.  Disclosures will be made for the purpose of controlling disease, injuries or disabilities.  Additionally, we may disclose your protected health information, if authorized by law, of a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

§    Reporting Abuse or Neglect.  The Center for Pediatric and Adolescent Medicine may disclose your protected health information to the Department of Social Services as required by law if we believe that you have been a victim of abuse, neglect or domestic violence.  Disclosure of this nature will be made consistent with the requirements of applicable federal and North Carolina laws.

§    Law Enforcement Agencies.  The Center for Pediatric and Adolescent Medicine may disclose protected health information, so long as applicable legal requirements are met, for state or local law enforcement purposes.  These law enforcement purposes include: (a) legal processes and otherwise required by law, (b) limited information requests for identification and location purposes, (c) pertaining to victims of a crime, (d) suspicion that death or injury has occurred as a result of criminal conduct, (e) in the event that a crime occurs on the premises of the Center for Pediatric and Adolescent Medicine, (e) medical emergency occurred not on the premises but is likely a result of criminal conduct.

§    Government and Military Agencies.  The Center for Pediatric and Adolescent Medicine may disclose your PHI to federal officials for intelligence and national security activities authorized by law.  This includes disclosures to the armed forces as required by the military command authorities.  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.

§    Health Oversight Agencies.  The Center for Pediatric and Adolescent Medicine 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.

§    Judicial and Legal Proceedings.  The Center for Pediatric and Adolescent Medicine 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.  Efforts will be made to ensure that the disclosure is limited to the minimum PHI specifically requested.

§    Organ and Tissue Donation.  The Center for Pediatric and Adolescent Medicine 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.

§    Coroners, Medical Examiners and Funeral Directors.  The Center for Pediatric and Adolescent Medicine 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 appropriate duties.

§    Avert a Threat to Health or Safety.  The Center for Pediatric and Adolescent Medicine may use and disclose your PHI when necessary to reduce or prevent a serious threat to you or 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.

§    Disaster Relief Agencies.  Information on your location, medical condition, or death may be disclosed to disaster relief organizations such as the Red Cross and other public or private entities to assist with their efforts.

§    Disclosure to Family or Friends.  We may disclose your health information to a family member or other person to the extent necessary to help with your care and treatment or with payment for your care and treatment, but only if you give authorization.  If we determine it is in your best interest based on our professional judgment or experience with common practices, we may allow another person to pick up filled prescriptions, medical supplies or other forms of protected health information.

§    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 for a copy of this notice at any time.  To obtain a paper copy of this notice, inquire at either of our office locations, contact the Privacy Administrator at the address found at the end of the notice, or access our web site at www.cpamed.com.

§    Right to Request Authorization of Uses and Disclosures.  The Center for Pediatric and Adolescent Medicine will obtain your written authorization (form F-3000) for uses and disclosures that are not identified by this notice or permitted by applicable law.  You may revoke any authorization you provided to us regarding the use and disclosure of your PHI at any time in writing using the Revocation of Use and Disclosure form (F-3100).  After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization.  Please note that we are required to retain records of your care and treatment.

§    Right to Request Restrictions.  You have the right to request restrictions in our use or disclosure of your PHI for treatment, obtaining 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 PHI, you must make your request in writing to the Privacy Administrator using the Restrictions of Use and Disclosure form (F-4000).  The request must describe in a clear and concise fashion: (a) the information you wish restricted, (b) whether you are requesting to limit the Center for Pediatric and Adolescent Medicine' use, disclosure or both, (c) to whom you want the limits to apply.

§    Right to Request Confidential Communications.  You have the right to request that the Center for Pediatric and Adolescent Medicine communicate with you about 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 confidential communication, you must make a written request using the Confidential Communication Request form (F-4100) specifying the requested method of contact, or the location where you wish to be contacted.  We will accommodate reasonable requests.  You do not need to give a reason for your request.

§    Rights to Request an Inspection or Copy.  You have the right to inspect and obtain a copy of your PHI including patient medical and billing records, but not including certain information that have restrictions on access such as psychotherapy notes.  You must submit your request in writing to the Privacy Administrator using the Request to Inspect or Copy form (F-5000), in order to inspect and/or obtain a copy of your PHI.  The Center for Pediatric and Adolescent Medicine will charge a fee for the costs of copying, mailing, labor and supplies associated with your request as determined by NC Law.  We 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.

§    Right to Request an Amendment.  You may ask us to amend your protected 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 the Center for Pediatric and Adolescent Medicine.  You must submit your amendment request in writing to our Privacy Administrator using the Request to Amend form (F-6000).  You must provide a reason that supports each of your requests for an amendment.  The Center for Pediatric and Adolescent Medicine will deny your request if you fail to complete the Request to Amend form in its entirety.  Also, we may deny your request if you ask to amend information that is in our opinion: (a) accurate and complete, (b) not part of the PHI kept by or for the Center for Pediatric and Adolescent Medicine, (c) not part of the PHI which you would be permitted to inspect and copy;  (d) not created by the Center for Pediatric and Adolescent Medicine, unless the individual or entity that created the information is not available to amend the information.

§    Right to Request an Accounting of Disclosures.  You have the right to request an "accounting of disclosures."  The accounting is a list of certain non-routine disclosures the Center for Pediatric and Adolescent Medicine has made of your PHI for non-treatment, payment or operational purposes.  Use of your PHI as part of the routine patient care is not a documental requirement.  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 our Privacy Administrator using the Request for an Accounting form (F-7000).  All requests for an accounting 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 October 1, 2003.  The first list you request within a 12-month period is free of charge, but the Center for Pediatric and Adolescent Medicine may charge you for additional lists within the same 12-month period.  The Center for Pediatric and Adolescent Medicine will notify you of the costs involved with additional requests, and you may withdraw your request before any costs are incurred.

§    Right to File a Complaint.  If you believe your privacy rights have been violated, you may file a complaint with the Center for Pediatric and Adolescent Medicine or with the Secretary of the Department of Health and Human Services (DHHS).  To file a complaint with the Center for Pediatric and Adolescent Medicine, contact our Privacy Administrator at the address listed below.  All complaints must be submitted in writing.  Please utilize our Formal Complaint form    (F-8000) or submit your name, address, and a telephone number where we may contact you, and a description of the complaint.  Please provide as much information as possible so that the complaint can be properly investigated.  Neither the Center for Pediatric and Adolescent Medicine nor any of its affiliates will retaliate against a person who files a complaint with us or with the Secretary of the Department of Health and Human Services.

The Center for Pediatric and Adolescent Medicine 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 respect to that information.  We are required to abide by the terms of the notice effective our opening date, October 1, 2003.

If you would like a paper copy of this notice, have questions about it, believe its terms or any the Center for Pediatric and Adolescent Medicine privacy policy and procedures has been violated with respect to protected health information about you, or merely need to inquire about certain request forms, please contact us immediately in writing via the Center for Pediatric and Adolescent Medicine address or by phone.  The Department of Health and Human Services contact information is included for your convenience.

US Department of Health and Human Services

200 Independence Avenue SW

Washington, DC  20201

202-619-0257

877-696-6775

704-799-2878

Center for Pediatric and Adolescent Medicine, PA
136 Gateway Boulevard - Suite A
Mooresville, NC 28117-5608
Fax: 704-799-1627