ALL patients are seen at our Portsmouth office on Saturday and Sunday for sick visits from 9-12 am

Offices:

Hampton

603.929.3838

55 High Street
Suite 102
Hampton, NH 03842

Portsmouth

603.436.7171

330 Borthwick Avenue
Suite 101
Portsmouth, NH 03801

Privacy policy for Pediatric Associates in Exeter, Hampton and Portsmouth, NH

Notice of  Privacy Policies

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


I.      Who We Are

   This Notice describes the privacy practices of
   Pediatric Associates of Hampton & Portsmouth, P.C. (the “Practice”).
II.      Our Privacy Obligations
    We are required by law to maintain the privacy of medical and health imformation about you (‘Protected Health Information”) and to provide you with this Notice of our legal duties and privacy practices with respect to Protected Health Information. When we use or disclose Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).
III.    A.   Use and Disclosure With Your Consent. Except in an emergency or other special circumstances, before providing treatment to you, we will ask you to read and sign a written consent to our use and disclosure of Protected Health Information for purposes of treatment provided to you, obtaining payment for services provided to you and for our health c are operations ( e . g., internal  administration, quality improvement and customer service) (“Your Consent”) as detailed below:

•    Treatment. We use and disclose Protected Health Information to provide treatment and other services to you--for example, to diagnose and treat your injury or illness. In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related
benefits and services that may be of interest to you. We may also disclose Protected Health Information to other providers involved in your treatment.
•    Payment.  We may use and disclose Protected Health Information to obtain
 payment for services that we provide to you--for example, disclosures to claim
 and obtain payment from your health insurer, HMO, or other company that
 arranges or pays the cost of some or all of your health care (“Your Payor”), or
 to verify that Your Payor will pay for health care.
•    Health Care Operations. We may use and disclose Protected Health Information for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness o f the care that we deliver to you. For example, we may use.
Protected Health Information to evaluate the quality and competence of our  physicians, nurses and other health care workers. We may disclose Protected  Health Information to our office manager in order to resolve any complaints you may have and ensure that you have a pleasant visit with us.


B. Use or Disclosure with Your Authorization.  As described above, Your Consent only permits us to use Protected Health Information for purposes of treatment, payment and our health care operations. We may use or disclose Protected Health Information for any reason other than treatment, payment and health care operations only when (1) you give us your authorization on our authorization form (“Your Authorization”) or (2) there is an exception described in Section IV below. Further, you may revoke Your Authorization, except to the extent that we have taken action m reliance upon it, by delivering a written revocation statement to the Office Manager identified below. [Implementation guideline: a provider that maintains psycho therapy notes may wish to state that the individual ‘s authorization is necessary to use psychotherapy notes for treatment, payment and health care operations under certain circumstances under 164.508(a) (2).] [Implementation guideline.’ the authorization form needs to comply with more stringent state laws. In particular, consider state laws regulating use and disclosure of disease/illness-specific health information, such as HI V/AIDS.]

iv. Uses and Disclosures without Your Consent or Your Authorization

     A.          Use or Disclosure For Treatment. Payment and Health Care Operations without Your Consent or Your Authorization.

   B.              Disclosure to Relatives and Close Friends. We may use or disclose Protected Health Information to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we (1) obtain your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer that you do not object to the disclosure.

                     If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that is directly relevant to the person’s involvement with your health care.
C. Marketing Communications. We may use or disclose Protected Health
Prevent or lessen a serious and imminent threat to a person’s or the public’s health or
safety.
M.     Specialized Government Functions. We may use and disclose Protected Health Information to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances required by law.
N.       ‘Workers’ Compensation. We may disclose Protected Health Information as authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs.
We may use or disclose Protected Health Information for purposes of treatment, obtaining payment and our health care operations without Your Consent or Your Authorization under the following three circumstances: (1) when you require emergency treatment; (2) when we are required by law to treat you and we attempt to obtain Your Consent, but are unable to obtain it; and (3) when we attempt to obtain Your Consent but are unable to obtain it due to substantial barriers to communicating  with you ( e . g . , you are unconscious o r  otherwise incapacitated) and you u would have consented in the absence of the barriers.

V.     Your Individual Rights

          A.    For Further information; Complaints. If you desire further information
about your privacy rights, are concerned that we have violated your privacy rights or
disagree with a decision that we made about access to Protected Health Information, you
may contact our office Manager. You may also file written complaints with the Director,
Office for Civil Rights of the U.S. Department of Health and Human Services. Upon
request, the Office Manager will provide you with the correct address for the Director.
We will not retaliate against you if you file a complaint with us or the Director.
         B.    Right to Request Additional Restriction. You may request restrictions on
our use and disclosure of Protected Health Information (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. All requests for such restrictions must be made in writing. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction. If you wish to request additional restrictions, please obtain a request form from our Office Manager and submit the completed form to the Office Manager. We will send you a written response.
 
        C.     Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to receive Protected Health Information by alternative means of communication or at alternative locations.

         D.    Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. AU requests for access must be made in writing. Under limited circumstances, we may deny you access to your records. If you desire access to your records, please obtain a record request form from the Office Manager and submit the completed form to the Office Manager. If you request copies, we will charge you [$0.25] for each page.
        You should take note that, if you are a parent or legal guardian of a minor, certain portions of the minor’s medical record will not be accessible to you (for example, records

Information to identify health-related services and pro ducts that may be beneficial to your health and then contact you about the services and products. If you do not want to receive these marketing communications in the future, you may contact our Office Manager at
(603) 436-7171.
           D.   Public Health Activities. We may disclose Protected Health Information for the following public health activities and purposes:’ (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.

           E.   Victim of Abuse, Neglect or Domestic Violence. We may disclose Protected Health Information without Your Consent or Your Authorization if we reasonably believe you are a victim of abuse, neglect or domestic violence to a government authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence.
          F.    Health Oversight Activities. We may disclose Protected Health Information to a health oversight agency that oversees the health care system and ensures compliance with the rules of government health pro grams such as Medic are or Medicaid.

          G.    Judicial and Administrative Proceedings. We may disclose Protected Health Information in the course of judicial or administrative proceeding in response to a legal order or other lawful process.

          H.    Law Enforcement Officials. We may disclose Protected Health Information to the police or other law enforcement officials as required by law or in compliance with a court order.

          I.     Decedents. We may disclose Protected Health Information to a coroner or
medical examiner as authorized by law.

         J.     Organ and Tissue Procurement. We may disclose Protected Health Information to organizations that facilitate organ, eye or tissue procurement, banking or transplantation1

         K.    Research. We may use or disclose Protected Health Information without your consent or authorization if an Institutional Review Board approves a waiver o f authorization for disclosure.

         L.    Health or Safety. We may use or disclose Protected Health Information to transmitted disease diagnosis and treatment, chemical dependence treatment, prenatal care, care received by a married minor, and contraception and/or family planning services).
 
         E.    Right to Amend Your Records. You have the right to request that we amend Protected Health Information maintained in your medical record file or billing records. If you desire to amend your records, please obtain an amendment request form from the Office Manager and submit the completed form to the Office Manager. All requests for amendments must be in writing. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.

         F.    Right to Receive An Accounting of Disclosures. Upon written re4uest, you may obtain an accounting of certain disclosures of Protected Health Information made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, we will charge you [$1.00 per page] of the accounting statement.

          G:    Right to Receive Paper Copy of this Notice. Upon written request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically.

VI. Effective Date and Duration of This Notice

          A. Effective Date: This Notice is effective on April 14, 2003.

          B. Right to Change Terms of this Notice. We may change the terms of this Notice at anytime. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the revised notice in waiting areas of the Practice. You may also obtain any revised notice by contacting the Office Manager.

VII.     Office Manager

       You may contact the Office Manager at:

              Pediatric Associates of Hampton & Portsmouth, P.C.
              330 Borthwick Aye, Suite 202
              Portsmouth, NH 03801
              603-436-7171
              Fax Number: 603-433-5931