THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU, OR YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU, OR YOUR CHILD CAN GET ACCESS TO THIS INFORMATION.

It is understood that unless a child is of legal age, has been emancipated by law or is otherwise authorized by law to consent to Medical treatment, either a parent or legal guardian will assume the rights and responsibilities of the patient when it comes to protection and access to the PHI.

If you have questions about this Notice, please contact our office at (804) 658-5385 or write to Pediatric Headache Center of Richmond, PLLC, 2500-B Gaskins Road, Richmond, VA 23238.

WHO WILL FOLLOW THIS NOTICE

This Notice describes health information practices at Pediatric Headache Center of Richmond, PLLC. (“PHCR”) including those of:
Any health care professional permitted to provide you or your child with health service or enter information into you or your child’s medical record(s):
All office locations of PHCR; and
All employees, staff, and other personnel of PHCR.
Medical Students that rotate through our office.

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand medical information about you or your child regarding health is personal. We are committed to protecting medical information about you or your child. We create a record of the care and services you or your child receive at PHCR. We need this record to provide you or your child with quality care and to comply with certain legal requirements. This Notice applies to all the records of you or your child’s care generated by PHCR. Whether made by PHCRs’ personnel or your doctor, and whether made in writing or on the computer/ This Notice will tell you about the ways in which we may use and disclose medical information about you or your child. We also describe your or your child’s rights and certain obligations we have regarding the use and disclosure of medical information. Federal law requires that we: make sure medical information is kept private; give you this notice of our legal duties and privacy practices with respect to medical information about you or your child; follow the terms of the notice that is currently in effect.

WRITTEN ACKNOWLEDGEMENT

You, or for a minor a parent or legal guardian will be asked to sign a written statement or acknowledgement that he or she has received a copy of this Notice.

CHANGES TO THIS NOTICE

We may change our policies and this Notice at any time. Changes will apply to medical information we already hold, as well as new information after the change occurs. We will post a copy of the current notice at www.pediatricheadachecenter.com. The notice will contain the effective date and the date of the revision. Upon your request, we will provide you with any revised Notice of Privacy Practice.

ROUTINE OR COMMON USES AND DISCLOSURES OF MEDICAL INFORMATION ABOUT YOU OR
YOUR CHILD

The following categories describe different ways we frequently use and disclose medical information. All of the ways we are permitted to use and disclose information will fall within one of the listed categories. For each category of uses or disclosures we will explain what we mean. Not every specific use or disclosure category will be listed, but we attempt to describe, in general terms, the types of uses and disclosures that fall within each category. For Treatment: We may use medical information about you or your child to provide medical treatment or services. We may disclose medical information about you or your child to doctors, nurses, technicians, laboratories, medical students, and clerical staff both inside and out PHCR who are involved in taking care of you or your child. For Payment: We may use and disclose medical information about you or your child so that treatment and services received at PHCR may be billed to, and payment may be collected from you, an insurance company or other third party. We may also tell your health plan about a treatment or diagnostic test your or your child are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. Business Associates: We are permitted by law to utilize Business Associates to carry out treatment, payment or health care operations / functions that may involve the use and disclosure of some of your or your child’s health information. We will only use such Business Associates when we believe it to be the most effect means for carrying out permissible treatment, payment of health care operations/functions. However, in any such instance, unless the disclosure of health information is to another health care provider for purposes of providing treatment to you or your child we will have entered into a formal Agreement with the Business Associate that requires the Business Associates to limit its use of such information to only the purpose for which it was disclosed by us. Appointment Reminders: We may use and disclose medical information to contact you by mail or telephone or other technologies as they become available to remind you of your or your child’s appointment for treatment or medical
care at PHCR. Our message will include the name of the practice, as well as the date and time of the appointment or a reminder that an appointment needs to be scheduled.
School, Daycare, Camp: In the case of our minor patients, we may use and disclose medical information that is required for your child to attend school, daycare or camp. Some organizations require the completion of specific forms. If we mail, fax or email this information rather than providing it directly to a parent or legal guardian, your
signature will need to be on the form prior to our release. Workplace: We may use and disclose medical information that is required for you to receive any type of FMLA or
workplace accommodation. Some organizations require the completion of specific forms. If we mail, fax or email this information rather than providing it directly to the requestor, your signature will need to be on the form prior to our release. Health Oversight Activities: We may use and disclose medical information to a health oversight agency for activities by law. These oversight activities include, but are not limited to: audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil right laws. As Required By Law: We will disclose medical information about you or your child when required to do so by federal, state or local law.

SPECIAL SITUATIONS

To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you or your child when necessary to prevent a serious threat to you or a child’s health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent or lessen the threat and may be required or permitted by Virginia and/or federal law.

Public Health Activities: We may disclose you or your child’s medical information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury, or disability. We may also disclose you or your child’s medical information, if directed by the public health authority to any other government agency that is collaborating with the public health agency.

For Communicable Disease Exposure: We may disclose your medical information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Lawsuits and Disputes: If you or your child are involved in a lawsuit or a dispute, we may disclose medical information about you or your child in response to a court or administrative order. We may also disclose medical information about you or your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain a court order protecting the information requested.

Law Enforcement: We may release medical information if asked to do so by a law enforcement official; in response to a court order, subpoena, warrant, summons or similar process; to identify or locate a suspect, fugitive, material witness, or missing person about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; about a death we believe may be the result of criminal conduct; about criminal conduct at PHCR; and in emergency circumstances to report a crime, the location of the crime or victims; or the identity, description or location of the person who committed the crime.

National Security and Intelligence Activites: We may release medical information about you or your child to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

YOUR OR YOUR CHILD’S RIGHTS REGARDING MEDICAL INFORMATION ABOUT THEM

You or your child have the following rights regarding medical information we maintain:

You have the right to inspect or to obtain copies of medical information: that may be used to make decisions about you or your child’s care. Usually, this includes medical and billing records. To inspect or obtain copies of medical information that may be used to make decisions about you or your child, you must submit your request in writing, or using the Authorization to Disclose form to: Pediatric Headache Center of Richmond, 2500-B Gaskins Road, Richmond, VA 23238, or via email to: phcr4u@icloud.com, or via fax to: 804.658.5507. If you request a copy of the information, we may charge a reasonable fee for the costs of copying, mailing or other expenses associated with your request. All copies will be provided in a readable hard copy form.

Right to Amend: If you feel medical information we have about you, or your child is incorrect or incomplete, you may ask for us to amend the information. You have the right to request an amendment for as long as the information is kept by or for PHCR. You must submit your request in writing and provide your reason for requesting the amendment. We could deny your request to amend a record if the information was not created by user if we determine the record is accurate. You may appeal, in writing, a decision by us not to amend a record.

You have the right to request a restriction or limitation on the medical information: we use and disclose about you or your child for treatment, payment or health care operations. You may also request that any part of your or your child’s medical information not be disclosed to family members or friends who may be involved in your /their care. Your request must state the specific restriction requested and to whom you want the restrictions to apply.

We are not required to agree to your request except for certain disclosures when you have paid for services out-of- pocket, in full. If we agree to the requested restriction, we may not use or disclose our medical information in violation of that restriction unless it is needed to provide emergency treatment of unless we otherwise notify you that we can no longer honor your request.

You have the right to request that a health plan not be informed of treatment which is paid for out-of-pocket, in full by you: PHCR will comply with such request.

You have the right to request a paper copy of this Notice: If you would like a paper copy of this Notice, please request one from our office, by phone or when you are in our office.

You have the right to be notified in the event of a breach of your protected health information: In the event of a breach of your protected health information, PHCR will notify you as required by law.

COMPLAINTS

If you believe you or your child’s privacy rights have been violated, you may file a complete with PHCR or with the Secretary of the Department of Health and Human Services. To file a complaint with PHCR, contact the office in writing at Pediatric Headache Center of Richmond, 2500-B Gaskins Road, Richmond, VA 23238. Neither you, nor your child will be penalized for filing a complaint.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this notice, or by state and federal laws that apply to us, will be made only with your written authorization. If you provide us with authority to use or disclose medical information about you or your child, you may revoke that authority, in writing, at any time. If you revoke you authorization, we will no longer use or disclose medical information about you or your child for the reasons covered by your written authorization. However we are unable, and not required, to take back any disclosures we have already made in reliance upon your prior authorization.

EFFECTIVE DATE OF THIS NOTICE

Effective Date: January 1, 2016