Notice of Privacy Practices - Kids First Pediatric Partners

Our Commitment to Your Privacy
We understand that medical information about you and your health is personal. We are committed to protecting your medical information. In conducting our business, we create records regarding you and the treatment and services provided to you. This personal health information is used to provide you with quality care and to comply with certain legal requirements.

We understand that these laws are complicated, and provide you with this notice to describe your rights, and obligations we have regarding the use and disclosure of your personal health information.

We are required by law to:

Maintain the privacy of your personal health information
Notify you following a breach of personal health information
Provide you with this notice of our legal duties and privacy practices with respect to information we collect and maintain about you.
Follow the terms of this notice, or the notice that is in effect at the time we use or disclose your personal health information.

Uses and Disclosures of your Medical Information
The following categories describe different ways in which we may use and disclose your personal health information.

Treatment. Our practice may use your personal health information to provide, coordinate, and manage your medical treatment. Your information can be shared by physicians, nurses and others involved in your care, and these individuals will collect and document information about you in your medical record. To insure continuity of your care, we may disclose your information to other health care professionals involved in your treatment. For example, we may ask you to have laboratory tests (such as blood or urine tests) at a lab outside of our office; we will use the results to help us reach a diagnosis. We may use your information to write a prescription for you, and to send it to your pharmacy.

Payment. We may use and disclose your personal health information so that treatments and services provided to you may be billed and payment collected from you, your insurance company or a third party. For example, we may need to give information about your office visit to your health plan so that they may reimburse us for your visit. We may also 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.

Health Care Operations. Our practice may use and disclose your personal health information to operate our business. For example, we may use your information to evaluate the quality of care
Communications with You. We may use your personal health information to contact you at the address, email address, and telephone numbers you provide us with. We may contact you about appointment reminders, missed appointments, registration or insurance updates, billing and payment matters, information about your care, and treatment choices available for you. Unless you request otherwise, we may leave messages about appointments on your phone.
Individuals Involved in Your Care. We may use or disclose the minimum necessary personal health information about you to a family member, or person you identify that is involved in your medical care. We also may disclose the minimum necessary information to someone who helps pay for your care. In an emergency or other situation where you are not able to identify your chosen person(s) to receive communications about you, we may exercise our professional judgment to determine whether such a disclosure is in your best interest, who is the appropriate person(s), and what personal health information is relevant to their involvement in your care. We may also disclose your personal health information to an organization which is assisting in a disaster relief effort, such as the American Red Cross, so that your family can be notified of your condition, status, and location.

Business Associates. We provide some services through other persons or companies that need access to your health information to carry out these services. The law refers to these persons or companies as our Business Associates. We may disclose, as allowed by law, your health information to our Business Associates so that they can do the job we have contracted with them to do. Examples of Business Associates include companies that assist with billing services and technology support. We require through written contract that our Business Associates use appropriate safeguards to ensure the privacy of your personal health information.
Research. Our practice may use and disclose your personal health information for research purposes in certain limited circumstances. We may use and disclose your personal health information to identify you as a potential candidate for a research study that has been approved by an Institutional Review Board (IRB). IRB approval is given after an evaluation of a proposed research project and its uses of personal health information with an emphasis on balancing the requirements of sound research with patients’ right to privacy. All other research purposes require your written authorization.

Uses and Disclosures of your Medical Information in Special Circumstances

The following categories describe unique scenarios in which we may use or disclose your personal health information.

Public Health Activities and Risks. We may disclose your personal health information for the following public health activities:

To maintain vital records such as births and deaths
To report health information to public health authorities for the purpose of preventing or controlling disease, injury, or disability
To report child abuse and neglect to authorities authorized by law to receive such reports
To report information about products and services under the jurisdiction of the U.S. Food and Drug Administration.
To alert a person who may have been exposed to a communicable disease or may at otherwise be at risk of contracting or spreading a disease or condition
To report information to your employer as required by law addressing work-related injury and illness or medical surveillance.
To notify authorities if we reasonably suspect an adult to be a victim of abuse, neglect, or domestic violence as authorized and required by law.

Health Oversight Activities. Our practice may disclose your personal health information to local, state and federal government authorities and agencies that oversee health care systems and ensure compliance with rules of government health programs, such as Medicare and Medicaid and under certain circumstances to the U.S. Military or Department of State.

Serious Threats to Health or Safety. We may use or disclose your health information to reduce or prevent a serious and imminent threat to a person’s or the public’s health or safety.

Lawsuits and Disputes. Our practice may use and disclose your personal health information in the course of a judicial and administrative proceeding, in response to an order of a court or other tribunal to the extent that such disclosure is authorized and, in certain conditions, in response to a subpoena, discovery request or other lawful process.

Law Enforcement. We may disclose your personal health information to the police or other law enforcement officials as part of law enforcement activities, in investigations of criminal conduct, in response to a court order, in emergency circumstances, or when otherwise required to do so by law.

Coroners, Medical Examiners and Funeral Directors. We may release personal health information about you to a coroner or medical examiner as necessary to identify a deceased person or to determine the cause of death. We may also release your personal health information to funeral directors as necessary for them to carry out their duties.

Organ and Tissue Donation. If you are an organ donor, we may release your personal health information to organizations that obtain or handle organ, eye or tissue transplantation. We may also release your information to an organ bank to arrange for donation and transplantation.

Military and Veterans. If you are a member of the military or a veteran, we may release your personal health information to the proper authorities so they may carry out their duties under the law.

Inmates. Our practice may disclose your personal health information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official as necessary so that they may carry out their duties under the law.

Workers’ Compensation. We may disclose your personal health information as allowed or required by state law relating to workers’ compensation benefits or similar programs.

Uses and Disclosures Requiring Your Written Authorization

We must obtain your written authorization for most uses and disclosures of psychotherapy notes, uses and disclosures for marketing purposes, and disclosures that would constitute the sale of health in formation. Additionally, other uses and disclosures not described in this notice will be made only when you give us your written permission on an authorization form. For instance, you will need to complete and sign an authorization form before we can send your personal health information to your life insurance company.

Use and Disclosure of Your Highly Confidential Information. Federal and state laws require special privacy protections for certain highly confidential information about you. This information may be a subset of your personal health information. In order to disclose your highly confidential information for a purpose other than those permitted by law, we must have your authorization.

Revocation of your Authorization. You may withdraw (revoke) your authorization at any time, except to the extent we have already taken action in reliance upon it, by delivering a written statement to the Practice Administrator identified below.

Uses and Disclosures Not Covered in this Notice. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by
applicable law. If you provide us with permission to use or disclose your protected health information, you may revoke that permission in writing at any time. If you revoke your
permission, we will no longer use or disclose your protected health information for the reasons covered by your written permission. Please understand that we are unable to take back any disclosures already made with your permission, and that we are required to retain records of
the care provided to you.

Your Rights Regarding Your Medical Information

Right to Request Confidential Communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. You do not need to give a reason for your request, and we will accommodate all reasonable requests.

Right to Request Restrictions. You have the right to ask us to restrict or limit the personal health information we use or disclose about you for treatment, payment, or healthcare operations. Unless required by law, we are not required to agree to all requests, however, if we do, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In addition, if you pay for a particular service in full, out-of‐pocket, and on the date of service, you may ask us not to disclose any related personal health information to your health plan for payment or health care operations purposes.
Right to Inspect and Copy. You may request access to your medical record and billing record maintained by our practice. Under limited circumstances, we may deny you access to a portion of your records as defined by law. If you would like access to your records, you must submit your request in writing. The Authorization for Release of Patient Health Information is available at our office, and on our website. If you request a copy of your records, we may charge you a cost-‐based fee, consistent with Illinois and Federal law, that includes labor for copying the record, supplies for creating the paper copy or electronic media if you request an electronic copy, and our postage costs if records are to be mailed. If you are denied access to your personal health information, you may request that the denial be reviewed. Our Practice Administrator, or a physician, 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 decision that is the outcome of the review.

Right to Amend. You may ask us to amend your 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 Practice Administrator. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request, and the reason supporting your request, in writing. We are not obligated to make all requested amendments, but will give all requests careful consideration. If your request is denied, you have the right to send a letter of objection that will then become part of your permanent medical record. Please note that even if we accept your request, we may not delete any information already documented in your medical record.

Right to an Accounting of Disclosures. All of our patients have the right to request an accounting of disclosures; a list of certain non-‐routine disclosures our practice has made of your personal health information for non-‐treatment, non-‐payment or non-‐operations purposes. Use of your personal health information 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 information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to the Practice Administrator. All requests for an accounting of disclosures must state a time period, which may not be longer than six years from the date of disclosure. 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. Right of Affected Individuals Following a Breach. If a breach of your personal health information occurs, you will receive a notification of such a breach by our practice as outlined by federal law.

Right to File a Complaint
If you would like more information about your privacy rights, if you are concerned that we may have violated your privacy rights, or if you disagree with a decision that we made about access to your health information, you may contact our Practice Administrator. You may also file written complaints with the Director of the Office of Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Practice Administrator will provide you the correct address for the Director. We will not retaliate against or penalize you if you file a complaint with us or the Director.

Practice Administrator
Caitlin Feld
Kids First Pediatric Partners
4709 Golf Road, Suite 200
Skokie, IL 60076
Phone: (847) 676-‐5394

Right to a Paper Copy of this Notice. Upon your request, you may obtain a copy of this notice, either by email or in a paper format. To obtain a copy of this request, please contact our Practice Administrator.

Effective Date and Duration of This Notice
This Notice is effective on September 23, 2013.
We reserve the right to change our privacy practices, policies and procedures and our Notice of Privacy