NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION

This notice describes how medical information about you may be used and disclosed and how you, your child or children may get access to this information. The Privacy Of Your Medical Information Is Important To Us. PLEASE READ IT CAREFULLY.

Our Legal Duty

We are required by law to maintain the privacy of your protected health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect April 14, 2003, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided that the changes are permitted by law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all protected health information that we maintain, including medical information we created or received before we made the changes. If we revise the terms of this Notice, we will prominently display and make available the revised notice at our offices. You may also obtain this Notice at www.RestonPediatrics.com.

Our Pledge Regarding Medical Information

The employees, medical staff and other health care professionals at Reston Pediatric Associates are committed to protecting your child or children’s medical information. Our records help us to provide your child or children with quality care and to comply with certain legal requirements. This notice applies to all records of your child or children’s care generated by the practice or your pediatrician. We have trained our entire staff on our policies and procedures and the new requirements of HIPAA regarding your health information and we will continually monitor our performance in this area. In addition, any business associates or partners with whom we share protected health information are contractually obligated to follow the terms and conditions of this Notice.

Written Acknowledgement

A parent or legal guardian will be asked to sign a written statement acknowledging that he or she has received a copy of this Notice. The Acknowledgement Form only serves to create a record that the parent or guardian has received a copy of the Notice. As part of the Privacy Standards we have updated our Consent Form. Every patient must receive our new Privacy Notice and execute a new Consent Form before this office may use your information for treatment, payment, or other health care operations (TPO). You may request restrictions on the uses and disclosures of your child or children’s medical information when completing the Consent Agreement. Any use or disclosure of your protected health information required for anything other than treatment, payment or health care operations requires you to sign an Authorization Form, which may be revoked at any time. Certain disclosures that are required by law, or under emergency circumstances, may be made without your Acknowledgement or Authorization. Under any circumstance, we will use or disclose only the minimum amount of information necessary from your medical records to accomplish the intended purpose of the disclosure. Since Reston Pediatric Associates treats mostly minors it is understood that unless a child is of legal age, has been emancipated by law or is other wise authorized by law to consent to Medical or Surgical treatment, either parent or legal guardian will assume the rights and responsibilities of the patient when it comes to protection and access to PHI.

Uses and Disclosures of Medical Information About Your Child or Children.

The following information describes different ways we may use or disclose your medical information. All of the ways we are permitted to use and disclose information will fall within one of these listed categories. Not every use or specific disclosure in a category will be listed, but we attempt to describe, in general terms, the types of uses and disclosures that fall within each category.

Treatment: We may use medical information about your child or children to provide medical treatment or services, as well as disclose medical information to clinicians (i.e., doctors, nurses, medical assistants, technicians, medical students, laboratories and clerical staff) who are involved in your child’s care at our practice or at outside practices upon request. For example, if a child has allergies, a doctor treating him or her may need to talk to an allergist about the condition to arrange for appropriate testing and/or treatment.

Payment: We may use and disclose medical information about your child or children so that the treatment and services you receive at Reston Pediatric Associates may be billed to, and payment may be collected from you, an insurance company or other third party. For example, we may need to send a copy of chart notes to the insurance company for individual consideration for payment on a service or we may need to give your health plan information to obtain approval for diagnostic testing.

Health Care Operations: We may use and disclose medical information about your child or children for operational reasons. These uses and disclosures are necessary to perform daily operations and to make sure all of our patients receive the best quality healthcare services we can offer. For example, we may use medical information to review our treatment and services and to evaluate our performance in caring for your child or children, or for accrediting agencies to evaluate our practice. We may also disclose information to medical providers and other practices for review and learning purposes or share information to evaluate how we are doing in comparison and to see where we can make improvements in the care and services we offer.

Business Associates: We are permitted by law to utilize Business Associates to carry out treatment, payment or health care operations functions that may involve the use and disclosure of some of your child or children’s health information. For example, we may use health care consultants to assist us in improving or upgrading services we offer our patients or we may use a billing service to handle some functions of billing. We will only use such Business Associates when we believe it to be the most effective means of carrying out permissible treatment, payment or health care operation functions. However, in any such instance, unless the disclosure of health information is to another health care provider for the purpose of providing treatment to your child or children, we will have entered into a formal Agreement with the Business Associate that requires the Business Associate to maintain the confidentiality of any patient information received and generally requires the Business Associate to limit its use of such information to only the purpose for which it was disclosed by us.

Others Involved in Your Health Care: We may release your child or children’s medical information to friends or family members who are involved in their medical care and/or someone who helps pay for their care. If possible, we will ask you permission beforehand. In addition, we may disclose medical information about you child or children to an entity assisting in a disaster relief effort so that your family can be notified about their condition, status and location.

Appointment Reminders: We may use and disclose medical information to contact you by mail or telephone or other technologies as they become available to remind you of a child’s appointment for treatment or medical care at Reston Pediatric Associates. Our messages will include the name of our practice as well as the date and time for your appointment.

School, Daycare, Camp: We may use and disclose medical information that is required for your child or children to attend school, daycare or camp. Some organizations require completion of specific forms while others request written prescriptions, notes or copies of medical records. If we mail or fax this information rather than providing it directly to a parent or guardian, an additional consent form will have to be signed. Communication Barriers and Emergencies: We may use and disclose your protected health information if we attempt to obtain consent from you but are unable to do so because of substantial communication barriers and we determine, using professional judgment, that you intend to consent to use or disclosure under the circumstances. We may use or disclose your protected health information in an emergency treatment situation. If this happens, we will try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If we are required by law or as a matter of necessity to treat you, and we have attempted to obtain your consent but have been unable to obtain your consent, we may still use or disclose your protected health information to treat you.

Health-Related Benefits and Services/Treatment Alternatives: We may use or disclose your child or children’s medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you or about health related benefits or services. For example, we may contact a home health agency to arrange nebulizer treatments.

Uses and Disclosures Based On Your Written Authorization: Other uses and disclosures of your protected health information will be made only with your specific Authorization, unless otherwise permitted or required by law as described below.

We May Also Use or Disclose Your Medical Information:

When required by the US Department of Health and Human Services as part of an investigation or determination of the practice’s compliance with relevant laws.

For public health activities including: the reporting of disease, injury, or disability, the reporting of domestic violence or child abuse or neglect, and the conduct of public health surveillance, investigation and/or intervention.

To a health oversight agency for oversight activities authorized by law, including audits, investigations, inspections, licensure or disciplinary actions, administrative and/or legal proceedings.

In the course of certain judicial or administrative proceedings

For law enforcement purposes such as complying with a court order, subpoena or warrant, and other law enforcement purposes

To a coroner, medical examiner or a funeral director

To an organ donation and procurement organization if you are an organ donor

To researchers conducting research that has been approved by an Institutional Review Board or the practices’ privacy board

To appropriate persons to prevent or lessen a serious threat to the health or safety of another person or the public

For military, national security, prisoner, and government benefit purposes. Note that disclosures for government benefits purposes are limited to health plans only

As authorized by laws relating to worker’s compensation or similar programs

As may otherwise be required under federal or state law, including but not limited to disclosures under the Virginia Health Records Privacy Act. _______________________________________________________________________

Your Rights Regarding Medical Information

Your Right to Inspect or Obtain Copies: You have the right to inspect or to obtain copies of medical information that may be used to make decisions about your child or children’s care. This right is subject to certain specific exceptions such as psychotherapy notes or information compiled in anticipation of or for use in a civil, criminal or administrative action or proceeding to which your access is restricted by law. To inspect or obtain copies of medical information you must make a request in writing to the Privacy Officer listed herein. We will charge a reasonable fee for providing a copy of your health records, at your request, which includes the cost of copying, postage, and preparation of the information. The fees are $0.50 per page for the first 50 pages and $0.25 per page thereafter + postage if mailed and $ 10.00 preparation fee. We may deny your request to inspect and copy in certain very limited circumstances. You may submit a written request to have this decision reviewed.

Your Right to Request an Amendment to Medical Information: You have the right to request we amend your protected health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request if we did not create the information or if we determine that the record is accurate. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement to be appended to the information you wanted amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people or entities you name, of the amendment and to include the changes in any future disclosures of that information.

Your Right to Request an Accounting of Disclosures: You have a limited right to receive an accounting of all disclosures we make to other persons or entities of you health information except to disclosures required for treatment, payment and healthcare operations, disclosures that require an Authorization, disclosure incidental to another permissible use or disclosure, and otherwise as allowed by law. We will not charge you for the first accounting in any twelve-month period; however, we will charge you a reasonable fee for each subsequent request for an accounting within the same twelve-month period. We will provide you with any disclosures made effective April 14, 2003 forward with the date on which we made the disclosure, the name of the person or entity to whom we disclosed your protected health information, a description of the protected health information we disclosed, and the reason for the disclosure.

Your Right to Request a Restriction or Limitation: You have the right to request a “Restriction or Limitation” on medical information we use or disclose. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). You may request that any part of your child or children’s medical information not be disclosed to family members or friends who may be involved in their care. Your request must state the specific restriction requested and to whom you want the restrictions to apply. With this in mind, please discuss any restrictions you wish to request with your or children’s physician. Please request all restrictions in writing to our Privacy Officer.

Your Right To Request Confidential Communications: You have the right to request receipt of confidential communications of your medical information by alternative means or at an alternative location. You must make your request in writing. We must accommodate your request if it is reasonable, specifies the alternative means or location, and continues to permit us to bill and collect payment from you.

Your Right To Recourse: You have the right to recourse if you privacy protections are violated. You may file a written complaint to us or to the Secretary of Health and Human Services if you believe that your privacy rights with respect to confidential information in you health records have been violated. All complaints must be in writing and must be addressed to the Privacy Officer (in the case of complaints to us) or to the person designated by the U.S. Department of Health and Human Services if we cannot resolve your concerns. Neither you, nor your child or children will be retaliated against for filing a complaint. ________________________________________________________________________

Address: Privacy Officer
RPA Administrative Office
6 Pidgeon Hill Drive
Suite 180
Sterling, VA 20165