NOTICE OF PRIVACY PRACTICES

THE PEDIATRIC CARE CENTER
AND
YOUNG ADULT CARE CENTER

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

We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. We make a record of the medical care we provide and may receive such records from others. We use these records to provide or enable other health care providers to provide quality medical care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this medical practice properly. We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. This notice describes how we may use and disclose your medical information. It also describes your rights and our legal obligations with respect to your medical information. If you have any questions about this Notice, please contact our Privacy Officer listed on the rear.

TABLE OF CONTENTS

A. How This Practice May Use or Disclose Your Health Information
B. When This Practice May Not Use or Disclose Your Health Information
C. Your Health Information Rights

1. Right to Request Special Privacy Protections
2. Right to Request Confidential Communications
3. Right to Inspect and Copy
4. Right to Amend or Supplement
5. Right to an Accounting of Disclosures
6. Right to a Paper or Electronic Copy of this Notice

D. Changes to this Notice of Privacy Practices
E. Complaints

The Pediatric Care Center and Young Adult Care Center (PCC) collects health information about you and stores it in a chart and in an electronic health record/personal health record. This is your medical record. The medical record is the property of this medical practice, but the information in the medical record belongs to you.

Protected health information (PHI) is health information created or received by your health care provider that contains information that may be used to identify you, such as demographic data. It includes written, electronic or oral health information that relates to your physical or mental health, the provision of health care to you, and payment for health care.

How this Medical Practice may Use or Disclose Your Health Information

The law permits us to use or disclose your health information for the following purposes:
Treatment: We may use and disclose PHI about you to provide, coordinate or manage your health care providers regarding your treatment and coordinating and managing your health care with others. For example, we may use and disclose PHI about you when you need a prescription, lab work, an x-ray, or other health care services. In addition, we may use and disclose PHI about you when referring you to another health care provider.

Payment: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures and supplies used. We might also share this information with your health plan for approval before we provide services.

Health Operations: Members of our staff may use the information in your health record for purposes of management, administration of the practice and offering quality health care services. Examples include quality evaluation, employee review and training, accreditation and licensing. We may also use and disclose this information as necessary for medical reviews, legal services and audits, including fraud and abuse detection and compliance programs and business planning and management. We may also share your medical information with our “business associates,” such as our billing service, that perform administrative services for us. We have a written contract with each of these business associates that contains terms requiring them and their subcontractors to protect the confidentiality and security of your protected health information. We may also share your information with other health care providers, health care clearing houses or health plans that have a relationship with you, when they request this information to help them with their quality assessment and improvement activities, their patient safety activities, their population–based efforts to improve health or reduce health care costs, their protocol development, case management or care-coordination activities, their review of competence, qualifications and performance of health care professionals, their training programs, their accreditation, certification or licensing activities, or their health care fraud and abuse detection and compliance efforts. We may also share medical information about you with the other health care providers, health care clearinghouses and health plans that participate with us in “organized health care arrangements” (OHCAs) for any of the OHCA’s health care operations.

In order to improve your quality of care by participating in an electronic exchange of your basic health information in the form of a Community Care Record, we have entered into an agreement with Children’s Hospital National Medical Center in the form of an Organized Health Care Arrangement. The Pediatric Care Center as a Covered Entity maintains its Designated Record Set in part through the use of an electronic health record (“EHR”) provided by Children’s National Medical Center (“Hospital”) to create a “Community Care Record (“CCR”). Certain protected health information is combined with that of other Covered Entities that participate in the CCR (each, a “Participating Covered Entity” and collectively, the “Participating Covered Entities”), to form a continuity of care record that serves as the single, longitudinal health record of services provided by the Participating Covered Entities to any particular patient. Hospital, also a Covered Entity, has access to the CCR and contributes PHI to the CCR with respect to inpatient and outpatient services provided by Hospital to Patients.

Through the CCR, the Participating Covered Entities have formed an organized system of health care in which the Participating Covered Entities participate in joint utilization review, research and/or quality assurance and improvement activities and as such qualify to participate in an Organized Health Care Arrangement (“OHCA”). As OHCA participants, all Participating Covered Entities may use and disclose the PHI contained within the CCR for the Treatment, Payment and Health Care Operations purposes of each of the OHCS participants.

If you do not wish to have your health information shared in this manner, you can request specific restrictions in writing by notifying our practice manager. The PCC may choose to deny your request for a restriction, in which case we will notify you of our decision. Once we agree to the requested restriction, the PCC may not violate that restriction unless use or disclosure of the relevant information is needed to provide emergency treatment. Such a request will be handled in the same manner as other requests for restriction on uses and disclosures of your PHI as noted below.

We may use or disclose PHI about you in the following circumstances, unless you tell us otherwise:

• Communication with family: We may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or, unless you had instructed us otherwise, in the event of death. In the event of a disaster, we may disclose information to a relief organization so they may coordinate notification efforts. We may also disclose information to someone who is involved with our care or helps pay for your care. If you are able and available to agree or object, we will give you the opportunity to object prior to making these disclosures. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.
• Marketing and other communications with you: We may contact you to provide appointment reminders, flu shot recommendations and other relevant health related information such as offered courses or services that may be of interest to you. We may receive compensation which covers our cost of reminding you to take and refill your medication, or otherwise communicate about a drug or biologic that is currently prescribed for you. We will not otherwise use or disclose your medical information for marketing purposes or accept any payment for other marketing communications without your prior written authorization, and we will stop any future marketing activity to the extent you revoke that authorization.We will not sell your health information.

Additional Uses and Disclosures Permitted or Required by Law

We may use or disclose your PHI without your permission or authorization in certain circumstances. Those circumstances
include:

• When the use or disclosure is required by federal, state or local law.
• When the use or disclosure is necessary for public health activities, including to, (1) prevent, control or report disease, injury or disabilities; (2) report vital events such as birth or death; (3) conduct public health surveillance, investigations and interventions; (4) collect or report adverse events and product defects; (5) notify a person who has been exposed to a communicable disease; and (6) report to an employer information about an individual who is member of the workforce.
• When the disclosure relates to victims of abuse, neglect or domestic violence.
• When the use or disclosure is for health oversight activities, such as to state or federal health agency which is authorized by law to oversee our operations.
• When the disclosure is for any judicial or administrative proceeding we may disclose PHI about you if the disclosure is expressly authorized by an order of a court or administrative tribunal.
• When the disclosure is for law enforcement purposes.
• When the use or disclosure relates to decedents we may disclose your PHI to a coroner or medical examiner for the performance of their duties as authorized by law.
• When the use or disclosure relates to Organ or Tissue Donation we may disclose your PHI to organizations involved in procuring, banking or transplanting organs and tissues.
• When the use or disclosure relates to research we may disclose PHI about you if such use or disclosure has been approved by an institutional review board or privacy board that has examined the research proposal and the research protocols which maintain the privacy of your PHI.
• We may, and are sometimes required by law, to disclose your PHI to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
• We will disclose proof of immunization to a school that is required to have it before admitting a student where you have agreed to the disclosure on behalf of yourself or your dependent.
• When the disclosure is for worker’s compensation we may disclose PHI about you to comply with worker’s compensation laws or similar programs.
• When the disclosure relates to specified government functions such as military and veterans activities, national security and intelligence activities, correctional institutions and law enforcement custodial situations.
• In the event that this medical practice is sold or merged with another organization, your health record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another physician or medical group.

WHEN THIS MEDICAL PRACTICE MAY NOT USE OR DISCLOSE YOUR HEALTH INFORMATION

Except as described in this Notice of Privacy Practices, the PCC will, consistent with its legal obligations, not use or disclose your PHI without your written authorization. If you do authorize the PCC to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

YOUR HEALTH INFORMATION RIGHTS:

You have certain rights regarding your PHI. These rights include:

The right to inspect and copy your PHI. For as long as the PCC holds your PHI, you may inspect and obtain a copy of such information. The PCC may deny your request to inspect or copy your PHI in certain circumstances. You have the right to request a review of this decision.

To access your medical information, you must submit a written request to the PCC’s practice manager detailing what information you want access to, whether you wish to inspect or receive a copy of your PHI, and if you wish a copy, your preferred form and format. We will provide copies in your requested form and format if it is readily producible, or we will provide you with an alternative format you find acceptable, or if we can’t agree and we maintain the record in an electronic format, your choice of a readable electronic or hardcopy format. The PCC may charge you a fee for the cost of copying, mailing or other costs incurred by us in complying with your request.

The right to request a restriction on uses and disclosures of your PHI. You may request that the PCC not use or disclose specific sections of PHI for the purposes of treatment, payment, or health care operations. Additionally, you may request that the PCC not disclose your PHI to family members or friends who may be involved in your care or for notification purposes as described in this Notice. In your request, you must specify the scope of restriction requested as well as the individuals for which you want the restriction to apply. Your request should be directed to the PCC’s practice manager.

The PCC may choose to deny your request for a restriction, in which case we will notify you of our decision. Once we agree to the requested restriction, the PCC may not violate that restriction unless use or disclosure of the relevant information is needed to provide emergency treatment. The PCC may terminate the agreement to a restriction in some instances.

The right to request to receive confidential communications by alternative means or at an alternative location. You have the right to request that the PCC communicate with you through alternative means or at an alternative location. We will make every effort to comply with reasonable requests. Requests should be made in writing to the PCC’s practice manager.

The right to request an amendment of your PHI. During the time that the PCC holds your PHI, you may request an amendment of your information. The PCC may deny your request in some instances. However, should we deny your request for amendment, you have the right to file a statement of disagreement with us. In turn, the practice may develop a rebuttal to your statement. If it does so, we will provide you with a copy of the rebuttal. Requests for amendment must be submitted in writing to the PCC’s practice manager. Your written request must supply a reason to support the requested amendments.

The right to request an accounting of certain disclosures. You have the right to request an accounting of the PCC’s disclosures of your PHI made for purposes other than treatment, payment or health care operations a s described in this Notice. We are not required to account for disclosures (1) which you requested, (2) which you authorized by signing an authorization form, (3) to friends or family members involved in your care, and (4) certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing to our practice manager and should state the time period for which you wish the accounting to include up to a six-year period. The PCC is not required to provide an accounting for disclosures that take place prior to April 14, 2003. We will not charge you for the first accounting you request of any 12 month period. Subsequent accountings may require a fee based on the PCC’s reasonable costs for compliance of the request.

The right to a Paper or Electronic Copy of this Notice. You have a right to notice of our legal duties and privacy practices with respect to our health information, including a right to a paper copy of the Notice of Privacy Practices.

OUR RESPONSIBILITIES

The Pediatric Care Center is required to:

• Maintain the security and privacy of your PHI
• Notify you promptly if a breach occurs that may have compromised the privacy or security of your PHI
• Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you.
• Abide by the terms of this notice and provide a copy to you
• Notify you if we are unable to agree to a requested restriction.
• Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will make the revised notice available at all reception desks and any electronic internet website we maintain, and post a notice that there has been change. We will not use or disclose your health information without your authorization, except as described in this notice.

FOR MORE INFORMATION OR TO REPORT A PROBLEM

If you have questions, would like to request a restriction or need additional information, you may contact our practice manager, who serves as our Privacy Official, at 301-564-5887.

If you believe that your privacy rights have been violated, you have the right to relate your complaints verbally or in writing. Such complaints should be directed to our practice manager.

You may also send a written complaint to the United States Secretary of Department of Health and Human Services, Office for Civil Rights.

If you file a complaint, we will not take any action against you or change our treatment of you in any way.

EFFECTIVE DATE
September 23, 2013
THE PEDIATRIC CARE CENTER
And
YOUNG ADULT CARE CENTER
5612 Spruce Tree Avenue
Bethesda, Maryland 20814
301-564-5880