Privacy statement

You have the following rights:

• To see or get a copy of your medical record or other health information we have about you; and to receive that within 30 days of your request. We may charge a reasonable, cost-based fee.

• To ask us to correct health information about you that you think id incorrect or incomplete. We may say “no” to your request, but will tell you why in writing within 60 days.

• To ask us to contact you in a specific way (home, office, mobile phone) or send mail to a different address. Reasonable requests will be honored.

• To ask that we not share or use certain health information for treatment, payment or operations. We are not required to agree to your request, especially if it would affect your care. Example, lab work and imaging require a diagnosis which would be available to those performing and billing for those services. While we do not bill insurance, we may collect insurance information for any outside lab or imaging that is required.

• We do not collect any insurance information for Tots N Teens Pediatric Housecalls, LLC., and will not share our visit information with your health insurer unless it is required by law. If you use a health savings card to pay for your visit, your insurer may become aware of the visit. You will receive a copy of the visit information which you may give to your Primary Care Provider.

• To a list of any times we’ve shared your health information for a period of 6 years.

• To a written copy of this privacy notice at any time.

• Choose someone to act for you: 1). Parents may list 2-3 adult persons who may be with child for a visit after the first initial visit with parent. (ie: babysitter, grandparent); 2). Medical power of attorney or legal guardian - Legal documentation for these situations will be necessary.

• File a complaint if you feel your rights are violated. You can complain by contacting Tots N Teens, or you can file a complaint with the U.S. Dept. of HHS Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C.20201; call 1-877-696-6775. Or visit 222.hhs.gov/ocr/privacy/hipaa/complaints

• We do not share your information with anyone without your consent except as required by law. You have the choice to tell us to share information with your family or others involved in your care, or disaster relief situations. If you are unable to tell us your preference, we may share your information if we believe it is in your best interest, or will lessen a serious and imminent threat to health or safety.

• No information will be used for marketing purposes, sale of your information, fundraising efforts without your written permission.

How we may use your health information:

• To treat you. Patient health information can be used and shared with other professionals who are treating you. We may collect and use health insurance information and social security numbers if needed, to order labs or imaging for those providers to bill for their services.

• To run our office – we do not collect any social security numbers or health insurance information for our office. Our medical records are via CHARM health electronic medical records. CHARM is a HIPAA compliant company.

• Your health information may be used to help with public health and safety issues such as preventing disease, help with product recalls, report adverse reactions to medication, reporting suspected abuse, neglect, or domestic violence, and preventing or reducing serious threat to anyone’s health or safety.

• To comply with state or federal law.

• Work with a medical examiner or funeral director.

• Address workers compensation, law enforcement and other government requests as required by law.

• In response to lawsuits and/or legal action. ie: we can share health information in response to a court or administrative order, or in response to a subpoena.

Our responsibilities:

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and provide you with a copy.

• We will not use or share your information other than as described here unless you tell us we can in writing. You can change your mind at any time. Let us know in writing if you change your mind.

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available on the website, and in print if requested.