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As Required by the Privacy Regulations Created as a Result of the
Health Insurance Portability and Accountability Act of 1996 (HIPAA)




Northwest Pediatrics, Inc. is dedicated to maintaining the privacy of your child's individually identifiable health information (IIHI).  In conducting our business, we will create records regarding your child and the treatment and services we provide to him/her.  We are required by law to maintain the confidentiality of health information that identifies your child.  We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your child's IIHI.  By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:
     - How we may use and disclose your child's IIHI
     - Your child's privacy rights in their IIHI
     - Our obligations concerning the use and disclosure of your child's IIHI

The terms of this notice apply to all records containing your child's IIHI that are created or retained by our practice.  We reserve the right to revise or amend this Notice of Privacy Practices.  Any revision or amendment to this notice will be effective for all of your child's records that our practice has created or maintainerange
        of benefits), and we may provide your child's insurer with details regarding your child's treatment to determine if the insurer will cover, or pay for, your child's treatment.
     - To obtain payment from other third parties that may be responsible for such costs.
     - To bill you directly for services and items.
     - To other health care providers and entities to assist in their billing and collection efforts.

3.  Health Care Operations.  Our practice may use and disclose your child's IIHI to operate our business.  As examples of the ways in which we may use and disclose your child's information for our operations include, but are not limited to the following:
     - To evaluate the quality of care your child received from us, or to conduct cost-management and business
         planning activities for our practice.
     - To other health care providers and entities to assist in their health care operations under       certain circumstances.
     - To contact you and remind you of your child's appointment.
     - To inform you of health-related benefits or services that may be of interest to you.
     - When we are required to do so by federal, state or local law.


The following categories describe unique scenarios in which we may use or disclose your identifiable health information to the extent such use or disclosure is required by law:

1.  Public Health Risks.  Our practice may disclose your child's IIHI to public health authorities that are authorized by law to collect information for the purpose of:
     - Maintaining vital records, such as births and deaths
     - Reporting child abuse or neglect
     - Preventing or controlling disease, injury or disability
     - Notifying a person regarding potential exposure to a communicable disease
     - Notifying a person regarding a potential risk for spreading or contracting a disease or condition
     - Reporting reactions to drugs or problems with products or devices
     - Notifying individuals if a product or device they may be using has been recalled

2.  Health Oversight Activities.  Our practice may disclose your child's IIHI 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.

3.  Lawsuits and Similar Proceedings.  Our practice may use and disclose your child's IIHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding.  We also may disclose your child's IIHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

4.  Law Enforcement.  We may release IIHI if asked to do so by a law enforcement official:
     - Regarding a crime victim in certain situations, if we are unable to obtain the person s agreement
     - Concerning a death we believe has resulted from criminal conduct
     - In response to a warrant, summons, court order, subpoena or similar legal process
     - To identify/locate a suspect, material witness, fugitive or missing person

5.  Deceased Patients.  Our practice may release IIHI 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 jobs.

6.  Research.  Our practice may use and disclose your child's IIHI for research purposes in certain limited circumstances.  We will obtain your written authorization to use your child's IIHI for research purposes except when an Internal Review Board or Privacy Board has determined that the waiver of your authorization satisfies the following:  (i) the use or disclosure involves no more than a minimal risk to your child's privacy based on the following: (A) an adequate plan to protect the identifiers from improper use and disclosure; (B) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by lay); and (C) adequate written assurances that the Protected Health Information (PHI) will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted; (ii) the research could not practicably be conducted without the waiver; and (iii) the research could not practicably be conducted without access to and use of the PHI.

7.  Serious Threats to Health or Safety.  Our practice may use and disclose your child's IIHI when necessary to reduce or prevent a serious threat to 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 prevent the threat.

8.  Workers  Compensation.  Our practice may release your child's IIHI for workers  compensation and similar programs.

9.  Compliance.  We are required to disclose your child s IIHI to the Secretary of the Department of Health and Human Services or his designee upon request to investigate our compliance with HIPAA or to you upon request pursuant to section E.3 below.


You have the following right regarding the IIHI that we maintain about your child:

1.  Confidential Communications.  You have the right to request a restriction in our use or disclosure of your child's health and related issues in a particular manner or at a certain location.  For instance, you may ask us not to contact you at work.  In order to request a type of confidential communication, you must make a written request to the General Manager, specifying the requested method of contact., or the location where you wish to be contacted.  Our practice will accommodate reasonable requests.  You do not need to give a reason for your request.

2.  Requesting Restrictions.  You have the right to request a restriction in our use or disclosure of your child's IIHI for treatment, payment or health care operations.  Additionally, you have the right to request that we restrict our disclosure of your child's IIHI to only certain individuals involved in your child s care or the payment for 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 your child.  In order to request a restriction in our use or disclosure of your child's IIHI, you must make your request in writing to the General Manager.  Your request must describe in a clear and concise fashion:
     - The information you wish restricted;
     - Whether you are requesting to limit our practice s use, disclosure or both; and
     - To whom you want the limits to apply

3.  Inspection and Copies.  You have the right to inspect and obtain a copy of the IIHI that may be used to make decisions about your child, including patient medical records and billing records, but not including psychotherapy notes.  You must submit your request in writing to the General Manager in order to inspect and/or obtain a copy of your child's IIHI.  Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request.  Our practice 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.

4.  Amendment.  You may ask us to amend your child s 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 our practice.  To request an amendment, your request must be made in writing and submitted to the General Manager.  You must provide us with a reason that supports your request in writing.  Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the IIHI kept by or for the practice; (c) not part of the IIHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.

5.  Accounting of Disclosures.  All of our patients have the right to request an accounting of disclosures .  An accounting of disclosures  is a list of certain non-routine disclosures our practice has made of your child's IIHI for non-treatment, non-payment or non-operations purposes.  Use of your child's IIHI as part of the routine patient care in our practice is not required to be documented.  For example, the doctor sharing information with the nurse; or the billing department using your child's information to file your insurance claim.  We also will not provide an accounting of disclosures made to you about your child, or incident to a use or disclosure we are permitted to make as described above, or pursuant to an authorization.  In order to obtain an accounting of disclosures, you must submit your request in writing to the General Manager.  All requests for an accounting of disclosures  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 April 14, 2003.  The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period.  Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

6.  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 to give you a copy of this notice at any time.  To obtain a paper copy of  this notice, contact the General Manager.

7.  Right to File a Complaint.  If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services.  To file a complaint with our practice, contact our General Manager at Northwest Pediatrics, Inc., 7275 Sawmill Road, Dublin, OH 43016.  All complaints must be submitted in writing.  You will not be penalized for filing a complaint.

8.  Right to Provide an Authorization for Other Uses and Disclosures.  Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.  Any authorization you provide to us regarding the use and disclosure of your child's IIHI may be revoked at any time in writing.  After you revoke your authorization, we will no longer use or disclose your child's IIHI for the reasons described in the authorization.  Please note, we are required to retain records of your child's care.

Again, if you have any questions regarding this notice or our health information privacy policies, please contact the General Manager at the Dublin office location.

General Manager
Northwest Pediatrics, Inc.
7275 Sawmill Road
Dublin, OH 43016


© 2005 Northwest Pediatrics Inc.