NOTICE OF PRIVACY PRACTICES

PLEASE REVIEW IT CAREFULLY HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.
The following categories describe different ways that we use and disclose medical information. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
For Payment. We may use and disclose medical information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party. In addition, we may tell your health plan about a treatment you are going to receive in order to obtain necessary approval or to determine coverage of the treatment.
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 all doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you. .
Who Will Follow This Notice?
~Any health care professional authorized to enter information into your medical chart.
~All departments employees, staff, and other office personnel at all locations of the practice.

POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION:


This notice will inform you about the different 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.
The law requires us 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.

OTHER CATEGORIES OF OUR INFORMATION USE INCLUDE AND DISCLOSE


~Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for medical care.
~As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law.
~Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interests to you.
~Individual Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care.
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. All research projects, however, are subject to a special approval process to evaluate its use of medical information in order to balance the research needs with patient’s need for privacy. Before we use or disclose medical information for research, the project will have been approved through this research approval process. We will almost always ask for your specific permission if the researcher obtains access to your name, address or other information that reveals who you are.
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.
Treatment Alternatives. We may use and disclose medical information to inform you about, recommend possible treatment options or alternatives that may be of interest to you.

LESS FREQUENT USES AND DISCLOSURES OF YOUR PERSONAL INFORMATION INCLUDE:


~Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner, medical examiner, or funeral director to identify a deceased person, determine the cause of death, or to carry out their services.
~Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law such as audits, investigations, inspections, and licensure so that the government can monitor the health care system, government programs, and compliance with civil rights laws.
~Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution. Law Enforcement. We may release medical information if asked to do so by a law enforcement official.
~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, subpoena, discovery request or other lawful process, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. Military and Veterans. We may release medical information about you as required by military command authorities.
~National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
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~Organ and Tissue Donation. We may release medical information to for organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation . .
~Protective Services for the President and Others. We may disclose medical information about you to authorize federal officials so they may provide protection to the President, other authorized persons, and foreign heads of state or conduct special investigations.
~Public Health Risks. We may disclose medical information about you for public health activities including, but not limited to:
~Preventing or controlling disease, injury or disability;
~Reporting births and deaths;
~Reporting child abuse or neglect;
~Reporting reactions to medications or problems with products; ~Notifying people of recalls of products they may be using;
~Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
~Notifying the appropriate government authority if we believe a patient has been a victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law. 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.

NOTICE OF INDIVIDUAL RIGHTS


Right to an Accounting of Disclosures. This is a list of the disclosures we made of medical information about you. You must submit your request in writing to East Cobb Pediatrics and Adolescent Medicine. You must state a time period, which may not be longer than six years and may not include dates before February 26, 2003. Indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the cost 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 Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You may request an amendment for as long as the information is kept by us. Submit your request in writing to East Cobb Pediatrics and Adolescent Medicine stating a reason that supports your request. We may deny your request for an amendment if it is not in writing, does not include a reason to support the request, asks us to amend information that was not created by us (unless the person or entity that created the information is no longer available to make the amendment), is not part of the medical information kept by us, is not information which you would be permitted to inspect and copy, or the information is accurate and complete.

Right to Inspect and Copy. You have the right to insect and copy medical information that may be used to make decisions about your care, including medical and billing records. You must submit your request in writing to East Cobb Pediatrics and Adolescent Medicine. If you request a copy of the information, we are entitled to charge a fee for the costs of copying, mailing and 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 us 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 a Paper Copy of this Notice. You have the right to a paper copy of this notice., even if you have agreed to receive this notice electronically. To obtain a paper copy of this notice contact East Cobb Pediatrics and Adolescent Medicine.

Right to Request Confidential Communications. To request confidential communications, you must make your request in writing in to East Cobb Pediatrics and Adolescent Medicine. We will not ask you the reason for the request and will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information disclosed for treatment, payment or health care operations or to those who are involved in your care or the payment for your care, like a family member or friend. 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 emergency treatment. Make your request in writing to East Cobb Pediatrics and Adolescent Medicine. You must tell us: 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.

CHANGES TO THIS NOTICE


We reserve the right to change this notice and to make the revised notice effective for medical information we already have about you as well as any information we receive in the future. We will have an available a copy of the current notice with the effective date in the lower left-hand corner of the last page.

COMPLAINTS


If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact our HIPAA Policy Officer, Marietta office at 770-977-0094 or the Office Manager, Kennesaw office at 770-795-4553. 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 use will be made only with your written permission. If you provide us permission to use or disclose medical information about you, 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 provide to you. If you have any questions about this notice, please contact our
HIPAA Officer at 770-977-0094.
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