Privacy

NOTICE OF PRIVACY PRACTICES

Effective Date: September 1, 2003

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU OR YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice, please contact the CHILDREN’S SPECIALTY GROUP, PLLC (CSG) Administrative office at 757-668-7007.

WHO WILL FOLLOW THIS NOTICE?

• Any CSG health care professional authorized to enter information into your medical chart.
• All CSG employees, staff and other personnel of the above-described entities.

In addition, CSG may share medical information with each other for treatment, payment or hospital operations purposes described in this notice.

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about you and your health is personal. We are committed to protecting your medical information. We create a record of the care and services you receive at the Children’s Specialty Group, PLLC. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the providers at CSG, whether made by the CSG entity personnel or your personal doctor. This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

• make sure that medical information that identifies you is kept private;
• give you this notice of our legal duties and privacy practices with respect to medical information about you; and
• follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.

The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways that we are permitted to use and disclose information will fall within one of the categories.

For Treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students or other CSG and hospital entity personnel who are involved in taking care of you. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different departments of CSG may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside of the CSG who may be involved in your medical care after you leave our care, such as family members, or others we use to provide services that are part of your care. Clergy, not employed by treating agency, must have your consent to release information.

For Payment: We may use and disclose medical information about you so that the treatment and services you receive by a CSG provider may be billed to, and payment may be collected from, you, an insurance company or a third party. For example, we may tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations: We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to run CSG departments and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many hospital patients to decide what additional services the hospital should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students and other hospital personnel for review and learning purposes. We may also combine the medical information we have with medical information from other hospitals or medical practices to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.

Appointment Reminders: We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care.

Treatment Alternatives: We may use and disclose medical information to inform you about or recommend alternative treatments, therapies, health care providers or care settings that may be of interest to you.

Health Care Providers and Services: We may use and disclose medical information to tell you about affiliated health care providers and health care services that we provide that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care: With your written consent, we may release medical information about your child to a friend or family member who may be involved in your child’s medical care. We may also give information to someone who helps pay for his/her care. Unless there is a specific written request from you to the contrary, we may also tell your family or friends your child’s condition and that he/she is in the hospital. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

Research: Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another for the same condition. All research projects, however, are subject to a special approval process by a group of people (Institutional Review Board) who are not controlled by CSG. The IRB evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave CSG and affiliate entities. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at CSG and/or affiliates.

As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

SPECIAL SITUATIONS

Organ and Tissue Donation: If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation: We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks: We may disclose medical information about you for public health activities. These activities generally include the following:

• to prevent or control disease, injury or disability;
• to report births and deaths;
• to report the abuse or neglect of children and dependent adults;
• to report reactions to medications or problems with products;
• to notify people of recalls of products they may be using;
• to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and
• to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities: We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.

Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request (which may include written notice to you) or to obtain an order protecting the information requested.

Law Enforcement: We may release medical information if asked to do so by a law enforcement official:

• In response to a court order, subpoena, warrant, summons or similar process;
• To identify or locate a suspect, fugitive, material witness or missing person;
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct at the hospital; or
• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors: We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOUR CHILD.

You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your child’s care. Usually, this includes medical and billing records, but may not include some mental health information.

To inspect and copy medical information that may be used to make decisions about your child, you must submit your request in writing to the Children’s Specialty Group care provider who provided the care that is the subject of your request. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend: If you feel that medical information we have about your child is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by the practice.

To request an amendment, your request must be made in writing and submitted to the Children’s Specialty Group provider. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us or if the person that created the information is no longer available to make the amendment;
• Is not part of the medical information kept by or for CSG;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.

Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about your child other than our own uses for treatment, payment and health care operations, as those functions are described above.

To request this list or accounting of disclosures, you must submit your request in writing to the provider of your child’s care. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about your child for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about your child to someone who is involved in your care or the payment for your child’s care, like a family member or friend. For example, you could ask that we not use or disclose information about a procedure your child had.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

To request restrictions, you must make your request in writing to your child’s provider. In your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse).

Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to your child’s provider of care. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

You may obtain a copy of this notice at our website, www.csgdocs.org

To obtain a paper copy of this notice, contact your child’s health care provider.

CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about your child as well as any information we receive in the future. We will post a copy of the current notice in each practice location. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at one of the CSG sites for treatment of health care services, you may request a copy of the current notice in effect.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with Children’s Specialty Group or with the Secretary of the Department of Health and Human Services. To file a complaint with CSG send to: Children’s Specialty Group, Administrative Office, 811 Redgate Avenue, Norfolk, Virginia 23507. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us permission to use or disclose medical information about you by signing an authorization, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.