Pediatric Associates of West Tennessee, PLLC
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR IF YOU NEED MORE INFORMATION,
PLEASE CONTACT OUR PRIVACY OFFICER:
Privacy Officer: Tobi Callens
Mailing Address: 1501 Brayton Avenue, Dyersburg, TN 38024
Telephone: 731-285-4111
Fax: 731-285-4221
Email:
About This Notice
We are required by law to maintain the privacy of Protected Health Information (PHI) and to give you this Notice
explaining our privacy practices with regard to that information. You have certain rights and we have certain legal
obligations – regarding the privacy of your PHI, and this Notice also explains your rights and our obligations. We
are required to abide by the terms of the current version of this Notice.
What is Protected Health Information (PHI)?
Protected Health Information (PHI) is information that individually identifies you and that we create or get from you
or from another health care provider, a health plan, your employer, or a health care clearinghouse and that relates to
(1) your past, present, or future physical or mental health or conditions, (2) the provision of health care to you, or (3)
the past, present, or future payment for your health care.
How We May Use and Disclose Your PHI
We may use and disclose your PHI in the following circumstances:
For Treatment. We may use PHI to give you medical treatment or services and to manage and coordinate your
medical care. For example, we may disclose PHI to doctors, nurses, technicians, or other personnel who are
involved in taking care of you, including people outside our practice, such as referring or specialist
Physicians.
For Payment. We may use and disclose PHI so that we can bill for the treatment and services you get from us and
can collect payment from you, an insurance company, or another third party. For example, we may need to give your
health plan information about your treatment in order for your health plan to pay for that treatment. We also may tell
your health plan about a treatment you are going to receive to find out if your plan will cover the treatment. If a bill is
overdue we may need to give PHI to a collection agency to the extent necessary to help collect the bill, and we may
disclose an outstanding debt to credit reporting agencies.
For Health Care Operations. We may use and disclose PHI for our health care operations. For example, we may
use PHI for our general business management activities, for checking on the performance of our staff in caring for
you, for our cost-management activities, for audits, or to get legal services. We may give PHI to other health care
entities for their health care operations, for example, to your health insurer for its quality review purposes.
Appointment Reminders/Treatment Alternatives/Health-Related Benefits and Services. We may use and
disclose PHI to contact you to remind you that you have an appointment for medical care, or to contact you to tell you
about possible treatment options or alternatives or health-related benefits and services that may be of interest to you.
Minors. We may disclose the PHI of minor children to their parents or guardians unless such disclosure is otherwise
prohibited by law.
Personal Representative. If you have a personal representative, such as a legal guardian (or an executor or
administrator of your estate after your death), we will treat that person as if that person is you with respect to
disclosures of you PHI.
As Required by Law. We will disclose PHI about you when required to do so by international, federal, state, or
local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose PHI when necessary to prevent a serious
threat to your health or safety or to the health or safety of others. But we will only disclosure the information to
someone who may be able to help prevent the threat.
Business Associates. We may disclose PHI to our business associates who perform functions on our behalf or
provide us with services if the PHI is necessary for those functions or services. For example, we may use another
company to do our billing, or to provide transcription or consulting services for us. All of our business associates are
obligated, under contract with us, to protect the privacy of your PHI.
Organ and Tissue Donation. If you are an organ or tissue donor, we may use or disclose your PHI to organizations
that handle organ procurement or transplantation – such as 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 PHI as required by military
command authorities. We may also release PHI to the appropriate foreign military authority if you are a member of
a foreign military.
Workers’ Compensation. We may use or disclose PHI for workers’ compensation or similar programs that provide
benefits for work-related injuries or illness.
Public Health Risks. We may disclose PHI for public health activities. This includes disclosures to: (1) a person
subject to the jurisdiction of the Food and Drug Administration (“FDA”) for purposes related to the quality, safety or
effectiveness of an FDA-regulated product or activity; (2) prevent or control disease, injury or disability; (3) report
births and deaths; (4) report child abuse or neglect; (5) report reactions to medications or problems with products;
(6) notify people of recalls of products they may be using; (7) a person who may have been exposed to a disease or
may be at risk for contracting or spreading disease or condition; and (8) the appropriate government authority if we
believe a patient has been the victim of abuse, neglect, or domestic violence and the patient agrees or we are
required or authorized by law to make that disclosure.
Health Oversight Activities. We may disclose PHI to a health oversight agency for activities authorized by law.
These oversight activities include, for example, audits, investigations, inspections, licensure, and similar activities
that 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 PHI in response to court or
administrative order. We also may disclose PHI in response to a subpoena, discovery request, or other legal process
from someone else involved in the protecting the information requested. We may also use or disclose your PHI to
defend ourselves if you sue us.
Law Enforcement. We may release PHI if asked by a law enforcement official for the following reasons; 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; about a death we believe may be the result of criminal conduct; about criminal conduct on our premises; and 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.
National Security. We may release PHI to authorized federal officials for national security activities authorized by
law. For example, we may disclose PHI to those officials so they may protect the President.
Coroners, Medical Examiners, and Funeral Directors. We may release PHI to a coroner, medical examiner, or
funeral director so that they can carry on their duties.
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we
may disclose PHI to the correctional institution or law enforcement official if the disclosure is necessary (1) for the
institution to provide you with healthcare; (2) to protect your health and safety or the health and safety of others; or
(3) the safety and security of the correctional institution.
Uses and Disclosures That Require Us to Give You an Opportunity to Object and Opt Out
Individuals Involved in Your Care or Payment of Your Care. We may disclose PHI to a person who is involved
in your medical care or helps pay for your care, such as a family member or friend, to the extent it is relevant to the
person’s involvement in your care or payment related to your care. We will provide you with opportunity to object
to and opt out of such a disclosure whenever we practicably can do so.
Disaster Relief. We may disclose your PHI to disaster relief organizations that seek your PHI to coordinate your
care, or notify family and friends of your location or condition in a disaster. We will provide you with an
opportunity to agree or object to such a disclosure whenever we practicably can do so.
Your Written Authorization is Required for Other Uses and Disclosures
Uses and disclosures for marketing purposes and disclosures that constitute a sale of PHI can only be made with
your written authorization. Other uses and disclosures of PHI not covered by this Notice or the laws that apply to us
will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time
by submitting a written revocation to our Privacy Officer and we will no longer disclose PHI under the
authorization. Disclosures that we made in reliance on your authorization before you revoked it will not be affected
by the revocation.
Special Protections for HIV, Alcohol and Substance Abuse, Mental Health, and Genetic Information
Special privacy protections apply to HIV-related information, alcohol and substance abuse, mental health, and
genetic information. Some parts of this general Notice of Privacy Practices may not apply to these kinds of PHI.
Please check with our Privacy Officer for information about the special protections that do apply. For example, if we
give you a test to determine if you have been exposed to HIV, we will not disclose the fact that you have taken the
test to anyone without your written consent unless otherwise required by law.
Your Rights Regarding Your PHI
You have the following rights, subject to certain limitations, regarding your PHI:
Right to Inspect and Copy. You have the right to inspect and/or receive a copy of PHI that may be used to make
decisions about your care or payment for your care. But you do not have a right to inspect or copy psychotherapy
notes. We may charge you a fee for the costs of copying, mailing or other supplies associated with your request. We
may not charge you a fee if you need the information for a claim or benefits under the Social Security Act or any
other state or federal needs-based benefit program. We may deny your request in certain limited circumstances. If
we do deny your request, you have the right to have the denial of your request, and we will comply with the
outcome of the review.
Right to an Electronic Copy of Electronic Medical Records. If your PHI is maintained in one or more designated
record sets electronically (for example an electronic medical record or an electronic health record), you have the
right to request that an electronic copy of your record be given to you or transmitted to another individual or entity.
We may charge you a reasonable, cost-based fee for the labor associated with copying or transmitting the electronic
PHI. If you chose to have your PHI transmitted electronically, you will need to provide a written request to this
office listing the contact information of the individual or entity who should receive your electronic PHI.
Right to Receive Notice of a Breach. We are required to notify you by first class mail or by email (if you have
indicated a preference to receive information by email), of any breach of your Unsecured PHI.
Right to Request Amendments. If you feel that PHI we have 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 or for us. A
request for amendment must be made in writing to the Privacy Officer at the address provided at the beginning of
this Notice and it must tell us the reason for the request. We may deny your request 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 (1) was not created by us, (2) is not part of the medical information kept by or for us, (3) is not information that
you would be permitted to inspect and copy, (4) is accurate and complete. If we deny your request, you may submit
a written statement of disagreement of reasonable length. Your statement of disagreement will be included in your
medical record, but we may also include a rebuttal statement.
Right to an Accounting of Disclosures. You have the right to ask for an “accounting of disclosures,” which is a list
of the disclosures, including, (1) disclosures made for treatment, payment, and health care operation purposes, (2)
disclosures made with your authorization, (3) disclosures made to create a limited data set, and (4) disclosures made
directly to you. You must submit your request in writing to our Privacy Officer. Your request must state a time
period which may not be longer than 6 years before your request. Your request should indicate in what form you
would like the accounting (for example, on paper or by email). The first accounting of disclosures you request
within any 12-month period will be free. For additional requests within the same period, we may charge you for the
reasonable costs of providing the accounting. We will tell you what the costs are, and you may choose to withdraw
or modify your request before the costs are incurred.
Right to Request Restrictions. You have the right to request a restriction or limitation on the PHI we use or
disclose for treatment, payment, or health care operations. You also have the right to request a limit on the PHI we
disclose about you to someone who is involved in your care or the payment for you care, like a family member or
friend. We are not required to agree to your request. If we agree, we will comply with your request unless we
terminate our agreement or the information is needed to provide you with emergency treatment.
Right to Restrict Certain Disclosures to Your Health Plan. You have the right to restrict certain disclosures of
PHI to a health plan if the disclosure is for payment or health care operations and pertains to a health care item or
service for which you have paid out of pocket in full. We will honor this request unless we are otherwise required by
law to disclose this information. This request must be made at the time of service.
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. You may request a copy of this Notice at any time. You can get a copy of this
Notice at our website: http//www.kidsgetwell.com.
Right to Request Confidential Communications. You have the right to request that we communicate with you
only in certain ways to preserve your privacy. For example, you may request that we contact you by mail at a special
address or call you only at your work number. You must make any such request in writing and you must specify
how or where we are to contact you. We will accommodate all reasonable requests. We will not ask you the reason
for your request.
How to Exercise Your Rights
To exercise your rights described in this Notice, send your request, in writing, to our Privacy Officer at the address
listed at the beginning of this Notice. We may ask you to fill out a form that we will supply. To get a copy of this
Notice, contact our Privacy Officer by phone or email.
Changes to This Notice
The effective date of the Notice is stated at the beginning. We reserve the right to change this Notice. We reserve
the right to make the changed Notice effective for PHI we already have as well as for any PHI we create or receive
in the future. A copy of our current Notice is posted in our office and our website.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with us or the Secretary of the
Department Of Health And Human Services. To file a complaint with us, contact our Privacy Officer at the address
listed at the beginning of this Notice. All complaints must be made in writing and should be submitted within 180
days of when you knew or should have known of the suspected violation. There will be no retaliation against you for
filing a complaint.
Optional Provisions to be Included as Applicable:
Newsletters and Other Communications. We may use your PHI to communicate to you by newsletters, mailings,
or other means regarding treatment options, health related information, disease management programs, wellness
programs, or other community based initiatives or activities in which our practice is participating.
Fundraising Activities. We may use your demographic information to contact you in an effort to raise money for
awareness of certain medical conditions. Any fundraising letter you receive from us will provide you with
instructions on how to opt out of any future fundraising letters. We will not use your diagnosis to fundraise unless
you authorize us to do so in writing.
Research. We may use and disclose your PHI for research purposes, but we will only do that if the research has
been specially approved by an institutional review board or a privacy board that has reviewed the research proposal
and has set up protocols to ensure the privacy of your PHI. Even without that special approval, we may permit
researchers to look at PHI to help them prepare for research, for example, to allow them to identify patients who
may be included in their research project, as long as they do not remove, or take a copy of, any PHI. We may use
and disclose a limited data set that does not contain specific readily identifiable information about you for research.
But we will only disclose the limited data set if we enter into a data use agreement with the recipient who must agree
to (1) use the data set only for the purposes for which it was provided, (2) ensure the security of the data, and (3) not
identify the information or use it to contact any individual.
Foreign Language Version. If you have difficulty reading or understanding English, you may request a copy of this
notice in Spanish.
Medical Residents and Medical Students. Medical residents or medical students may observe or participate in
your treatment or use your PHI to assist in their training. You have the right to refuse to be examined, observed, or
treated by medical residents or medical students.
Psychotherapy Notes. Under most circumstances, without your written authorization we may not disclose the notes
a mental health professional took during a counseling session. However, we may disclose such notes for treatment
and payment purposes, for the state and federal oversight of the mental health professional, for the purposes of
medical examiners and coroners, to avert a serious threat to health or safety, or as otherwise authorized by law.
Research. We may use and disclose your PHI for research purposes, but we will only do that if the research has
been specially approved by an institutional review board or a privacy board that has reviewed the research proposal
and has set up protocols to ensure the privacy of your PHI. Even without the special approval, we permit researchers
to look at Phi to help them prepare for research, for example, to allow them to identify patients who may be included
in their research data set that does not contain specific readily identifiable information about you for research. But
we will only disclose the limited data set if we enter into a data use agreement with the recipient who must agree to
(1) use the data set only for the purposes for which it was provided, (2) ensure the security of the data, and (3) not
identify the information or use it to contact any individual.
