HIPAA - Notice of Privacy Practice

NOTICE OF PRIVACY PRACTICES

SEWICKLEY VALLEY PEDIATRIC & ADOLESCENT MEDICINE

Original Effective Date: April 1, 2003

This Notice was revised Effective: July 2, 2013, September 1, 2015

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

If you have any questions regarding this notice, you may contact our Privacy Officer at the following location:

Sewickley Valley Pediatrics

Attention Privacy Officer

119 VIP Drive, Suite 102

Wexford, PA 15090

724-935-6644 (phone)

724-935-9644 (fax)

HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT – CODE OF CONDUCT

Sewickley Valley Pediatrics values each person as an individual with rights and dignity: the right to quality healthcare; the right to privacy; and the right to an assurance that health information is both confidential and secure. The individual and family members have the right to question their health information and the use of it. This facility requests permission for disclosures not already authorized by law. Employees are trained to keep secure, private, and confidential all patient health information. Employees are updated on regulations and new policies, which make adherence to the regulations operational.

It is the value of Sewickley Valley Pediatrics to assure our families that no breach of patient health information privacy, security, or confidentiality will be tolerated. There exists disciplinary measures, up to and including termination, for those found in violation.

Sewickley Valley Pediatrics will act on your behalf to ensure that care is of the utmost quality and all regulations are met or exceeded to provide a welcoming environment.

ABOUT THIS NOTICE

Sewickley Valley Pediatrics is required by law to maintain the privacy of Protected Health Information 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 Protected Health Information, 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

“Protected Health Information” is information that individually identifies you and that we create or get from you or from another health care provider, 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.

USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION

We may use and disclose your Protected Health Information in the following circumstances:

1. Treatment

We may use or disclose your Protected Health Information to give you medical treatment/services and to manage/coordinate your medical care. For example, your Protected Health Information may be provided to a physician or other health care provider (like a specialist or lab) to whom you have been referred to ensure that the physician or other health care provider has the necessary information to diagnose or treat you or provide you with a service.

*If your child is receiving behavioral health services with Dr. Kristina Johnson @ SVPAM, she & the referring SVPAM provider will collaborate & share diagnostic, treatment, & therapy information as needed for the appropriate care of your child. Other SVPAM providers may review behavioral health information from Dr. Johnson ONLY as it is appropriate for current/future care & treatment of your child.

2. Billing & Payment

We may use and disclose your Protected Health Information so that we can bill for the treatment and services you receive from us and collect payment from you, a health plan or a third party. This use and disclosure may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. Some examples of payment uses and disclosures would include:

*Sharing information with your health insurer to determine whether you are eligible for coverage or whether proposed treatment is a covered service.

*Submission of a claim form to your health insurer.

*Providing supplemental information to your health insurer so that you health insurer can obtain reimbursement from another health plan under a coordination of benefits clause in your subscriber agreement.

*Sharing your demographic information (address, telephone number) with other health care providers who seek this information to obtain payment for health care services provided to you.

3. Health Care Operations

We may use and disclose Protected Health Information for our health care operations. For example, we may use your Protected Health Information to internally review the quality of the treatment and services you receive and to evaluate the performance of our team members in caring for you. We also may disclose information to physicians, nurses, medical students, medical technicians, and other authorized personnel for educational and learning purposes. Some examples of other health care operation purposes include:

*Accreditation, certification, licensing, and credentialing activities

*Health care fraud and abuse detection and compliance programs

*Conducting other medical review, legal services, & auditing functions

*Sharing information regarding patients with entities that are interested in purchasing

our practice and turning over patient records to entities that have purchased our

practice

4. Appointment Reminders/Treatment Alternatives/Health-Related Benefits

We may use and disclose Protected Health Information 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.

5. Minors

We may disclose the Protected Health Information of minor children to their

parents or guardians unless such disclosure is otherwise prohibited by law.

6. Research

We may use and disclose your Protected Health Information for research purposes,

but we will only do that if the research has been specially approved by an authorized institutional review board or a privacy board that has reviewed the research proposal and has set up protocols to ensure the privacy of your Protected Health Information. Even without that special approval, we may permit researchers to look at Protected Health Information 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 Protected Health Information. We may use and disclose a limited data set that does not contain specific readily identifiable information about you for research. However, 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 has provided, (2) ensure the confidentiality and security of the data, and (3) not identify the information or use it to contact any individual.

7. Individual involved in care or payment for care

We may disclose your protected health information to someone involved in your care or payment for your care, such as a spouse, a family member, or a close friend. For example, grandmother or a close friend brings the child in for a visit – we will obviously need to discuss the care and treatment for the child at that visit.

With regard to pediatric & adolescent medicine, we will share information with both parents, legal guardians and/or in the case of a custody dispute, to those persons identified in an Order from the Court. With regard to adolescent care, we reserve the right to adhere to patient confidentiality, except in situations involving possible abuse, and/or patient is exhibiting suicidal or homicidal ideations.

8. Notification purposes

We may use and disclose your protected health information to notify, or to assist in the notification of a family member, a personal representative, or another person responsible for your care, regarding your location, general condition or death. For example, if you need to be hospitalized, we may notify a family member of the hospital and your general condition. In addition, we may disclose your protected health information to a disaster relief entity, such as the Red Cross, so that it can notify a family member, personal representative, or another person involved in your care regarding your location, general condition or death.

9. Required by Law

We may use and disclose protected health information when required by international, federal, state or local law. For example, we may disclose protected health information to comply with mandatory reporting requirements involving births & death, child abuse, disease prevention and control, vaccine-related injuries, medical devise-related death and serious injuries, gunshot and other injuries by a deadly weapon or criminal act, driving impairments, and blood alcohol testing. For school-age children, we will provide immunization (shot) records to the schools to update their records, which are required by state law.

10. Other Public Health activities

We may use and disclose protected health information for public health activities including:

*Public health reporting – communicable disease reports

*Child abuse & neglect reports (CYS-Children & Youth Services)

*FDA-related reports and disclosures, for example – adverse events

*Public health warnings to third parties at risk of a communicable disease/condition

*OSHA requirements for workplace surveillance and injury reports

We may use and disclose Protected Health Information when necessary to prevent a serious threat to your health or safety or to the health or safety of others. But we will only disclose the information to someone who may be able to help prevent the threat.

11. Victims of Abuse, neglect or domestic violence

We may disclose Protected Health Information to 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.

12. Health oversight activities

We may use and disclose protected health information for purposes of health oversight activities authorized by law. These activities could include audits, inspections, investigations, licensure actions and legal proceeding. For example, we may comply with a Drug Enforcement Agency inspection of patient records.

13. Judicial and Administrative proceedings

If you are involved in a lawsuit or a dispute, we may disclose Protected Health Information in response to a court or administrative order. We also may disclose Protected Health Information in response to a subpoena, discovery request, or other legal process from someone else involved in the dispute, but only if efforts have been made to tell you about the request or to get an order protecting the information requested. We may also use or disclose your Protected Health Information to defend ourselves in the event of a lawsuit.

14. Law Enforcement Purposes

We may use and disclose protected health information for certain law enforcement purposes including to:

*Comply with legal process like a search warrant

*Comply with a legal requirement such as mandatory report of gun shot wounds

*Respond to a request for information for identification/location purposes

*Respond to a request for information about a crime victim

*Report a death suspected to have resulted from criminal activity

*Provide information regarding a crime on the premises

*Report a crime in an emergency

15. Coroners and Medical Examiners

We may use and disclose protected health information for purposes of providing information to a coroner or medical examiner for the purpose of identifying a deceased patient, determining a cause of death, or facilitating their performance of other duties required by law.

16. Funeral Directors

We may use and disclose protected health information for purposes of providing information to funeral directors as necessary to carry out their duties.

17. Organ & Tissue Donation

If you are an organ or tissue donor, we may use or disclose your Protected Health Information to organizations that handle organ procurement or transplantation, such as an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

18. Threat to Public Safety

We may use and disclose protected health information for purposes involving a threat to public safety, including protection of a third party from harm and identification and apprehension of a criminal. For example, in certain circumstances, we are required by law to disclose information to protect someone from imminent serious harm.

19. Specialized government functions

We may use and disclose protected health information for purposes involving specialized government functions including:

*Military & veterans activities

*National security and intelligence

*Protective services for the President & others

*Medical suitability determinations for the Department of State

*Correctional institutions & other law enforcement custodial situations

20. Workers’ compensation and similar programs

We may use and disclose protected health information as authorized by and to the extent necessary to comply with laws relating to workers’ compensation or similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault. For example, this would include submitting a claim for payment to your employer’s workers’ compensation carrier if we treat you for a work related injury (adolescent/young adult patients).

21. Business Associates

We may disclose Protected Health Information to our business associates who perform functions on our behalf or provide us with services if the Protected Health Information is necessary for those functions or services. For example, we may use another company to do our billing or provide consulting services for us. All of our business associates are obligated, under contract with us, to protect the privacy and ensure the security of your Protected Health Information.

22. Creation of de-identified Information

We may use protected health information about you in the process of de-identifying the information. For example, we may use your protected health information in the process of removing those aspects which could identify you so that the information can be disclosed to a researcher without your authorization.

23. Military and Veterans

If you are a member of the armed forces, we may disclose Protected Health Information as required by military command authorities. We also may disclose Protected Health Information to the appropriate foreign military authority if you are a member of a foreign military.

24. Public Health Risk

We may disclose Protected Health Information 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 suing; and (7) a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.

25. Data Breach Notification Purposes

We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.

26. Inmates

If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose Protected Health Information to the correctional institution or law enforcement official if the disclosure is necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution.

27. Incidental Disclosures

We may disclose protected health information as a by-product of an otherwise permitted use or disclosure. For example: other patients may overhear your name being paged in the waiting room, your chart may be seen on the exam room door or you may walk past our telephone triage room and overhear portions of a conversation.

USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT AND OPT OUT

Individuals Involved in Your Care or Payment for Your Care

Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health Information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.

Disaster Relief

We may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information 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.

Fundraising Activities

We may use or disclose your Protected Health Information, as necessary, in order to contact you for fundraising activities. You have the right to opt out of receiving fundraising communications. If you do not want to receive any fundraising materials, please submit a written statement to the SVPAM Privacy Officer.

YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES

The following uses and disclosures of your Protected Health Information will be made ONLY with your written authorization:

1. Most uses and disclosures of psychotherapy notes
2. Uses and disclosures of Protected Health Information for marketing purposes
3. Disclosures that constitute a sale of your Protected Health Information

Other uses and disclosures of Protected Health Information 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 Protected Health Information under the authorization. But the disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation.

SPECIAL PROTECTIONS FOR HIV INFORMATION, ALCOHOL AND SUBSTANCE ABUSE INFORMATION, MENTAL HEALTH INFORMATION AND GENETIC INFORMATION

Confidentiality of HIV-Related Information Act

Federal and state laws require that a person’s HIV status be kept confidential. Pennsylvania’s Act 148 (names the Confidentiality of HIV-Related Information Act) says that a health care provider cannot share HIV test results without written permission, except in limited instances. Such limited instances and permissible disclosures without consent may include when there is significant exposure (if appropriate rules are followed), for partner notification (if appropriate rules are followed), following a Court Order, to a health care provider for purpose of treatment, to a health care provider if necessary to provide emergency care, to the insurer for purposes of reimbursement, state/local vital statistics officer or public health agency, funeral directors

Health care, social service providers and clinical labs in Pennsylvania are required to report the names of people with HIV/AIDS to the local health department. The health department is required to keep HIV reports confidential, and the reporting of HIV test results is intended to help keep better track of the epidemic. The local health department reports how many people have HIV/AIDS and other non-identifying information to the state health department. They do not report the names.

Mental Health / Alcohol & Substance Abuse Information

The Pennsylvania Supreme Court has stated that the Pennsylvania Constitution provides protection for a patient’s right to privacy and protection from mental health information disclosure. Pennsylvania has passed several statutes which allow for certain types of information communicated by the patient to the provider to be precluded from disclosure by the provider. The patient is the only one who may authorize the disclosure of information and these privilege laws allow patients to prevent their health care provider from disclosing confidential information.

Pennsylvania has no specific state law regarding alcohol and substance abuse that would supersede the federal HIPAA Privacy standards.

Genetic Information

The majority of state legislatures have taken steps to safeguard genetic information beyond the protections provided for other types of health information. This approach to genetics policy is known as genetic exceptionalism, which calls for special legal protections for genetic information as a result of its predictive, personal and familial nature and other unique characteristics. Some commentators assert that treating genetic information the same as other health information is a more favorable approach. These individuals argue that genetic information is simply another form of health information and is, therefore, difficult to distinguish from other health information, all of which deserves equal protection under the law. With respect to privacy, Washington is the only state that explicitly treats genetic information the same as other health information by including genetic information in the definition of health care information under the state health privacy law. At this time, Pennsylvania has no law specifically addressing this matter.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

Right to Request Restrictions

You have a right to request that we further restrict use and disclosure of your protected health information to carry out treatment, payment, or health care operations, to someone who is involved in their care or the payment for your care, or for notification purposes. You also have the right to request a limit on the Protected Health Information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.

To request a further restriction, you must submit a written request to our privacy officer. The request must tell us: (a) what information you want restricted; (b) how you want the information restricted; and (c) to whom you want the restriction to apply. We are not required to agree to a request for a further restriction unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operations purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out of pocket” in full. If we do agree to the requested restriction, we may not use or disclose your Protected Health Information in violation of that restriction unless it is needed to provide emergency treatment.

Confidential communication

You have the right to request that we communicate your protected health information to you only in certain ways to preserve your privacy. For example, you might request that we only contact you by mail or at work. You must make any such request in writing and you must specify how or where we are able to contact you. In addition, if another individual or entity is responsible for payment, the request must explain how payment will be handled.

We will accommodate all reasonable requests. We will not ask you the reason for your request. We are not required to agree to requests for confidential communications that are unreasonable.

Accounting of disclosures

You have the right to ask for an “accounting of disclosures,” which is a list of the disclosures we made of your Protected Health Information. This right applies to disclosures for purposes OTHER than treatment, payment or healthcare operations as described in this Notice. If excludes disclosures we may have made to you, to family members or friends involved in your care or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions and limitations. Additionally, limitations are different for electronic health records. This 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 cost of providing the accounting. We will tell what the costs are, and you may choose to withdraw or modify your request before the costs are incurred.

Inspection and copying

You have the right to inspect and copy Protected Health Information that may be used to make decisions about your care or payment for your care. We have up to 30 days to make your Protected Health Information available to you and we may charge you a reasonable 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 for 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 reviewed by a licenses healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.

Right to a Summary or Explanation

We can also provide you with a summary of your Protected Health Information, rather than the entire record, or we can provide you with an explanation of the Protected Health Information which has been provided to you so long as you agree to this alternative form and pay the associated fees.

Right to an Electronic Copy of Electronic Medical Records

If your Protected Health Information is maintained in an electronic format (known as 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 will make every effort to provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request, your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

Right to Receive Notice of a Breach

You have the right to be notified upon a breach of any of your unsecured Protected Health Information. You will be notified in writing when a breach occurs.

Right to Request Amendments

If you feel that the Protected Health Information 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 your request. In certain cases, we may deny your request for an amendment. If we deny your request, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

Out-of-Pocket-Payments

If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.

Paper copy of privacy notice

You have a right to receive a paper copy of our Notice of Privacy Practices, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time.

CHANGES TO THIS NOTICE

We reserve the right to change this notice at any time. We further reserve the right to make any change effective for all protected health information that we maintain at the time of the change – including information that we created or received prior to the effective date of the change.

We will post a copy of our current notice in the waiting rooms and on our practice website. At any time, patients may review the current notice by contacting our privacy officer.

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 exercise your right to inspect and copy your Protected Health Information, you may also contact your physician directly. To get a paper copy of this Notice, contact our Privacy Officer by phone or mail.

COMPLAINTS

You may file a complaint with us or with the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated.

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 your complaint.

To file with the Secretary of HHS, mail your written complaint to: Secretary of the US Department of Health and Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201. Call 202-619-0257 or toll-free 877-696-6775 or go to the website of the Office of Civil Rights, www.hhhs.gov/ocr/hipaa/, for more information. There will be no retaliation against your for filing a complaint.

LEGAL EFFECT OF THIS NOTICE

This notice is not intended to create contractual or other rights independent of those created in the Federal Privacy rule.