Notice of Privacy Practices

This notice describes how your medical information may be used and disclosed and how you can obtain this information. PLEASE REVIEW CAREFULLY.

Uses and Disclosures

Treatment.

Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosis, and providing treatment. Such disclosures may include the results of laboratory tests and procedures made available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.

Payments.

Your health information may be used to seek payment from your health plan, from other sources of coverage such as other insurers, or from credit card companies that you use for paying services. An example would be your health plan may request and receive information on dates of service, services provided and medical condition being treated.

Health care operations.

Your health information may be used as necessary to support the daily activities of Pegasus Pediatric Practice. As an example, information on the services you received may be used to support financial reporting, projections, and steps for evaluating and promoting quality care.

Legal.

Your health information may be disclosed to public health agencies as required by law. An example would be if we are required to report some communicable diseases to the state’s public health department.

Other uses and disclosures requiring authorization.

Disclosure of your health information or its use for any purpose other than that above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. This decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before your notification to revoke your authorization.

Additional Uses of Information.

Your health information will be used by our staff to send you appointment reminders. Your health information may be used to send you information on the treatment and management of your medical condition. We may also send you information describing other health-related products and services.

Individual Rights.

You have certain rights under the federal privacy standards. These include:

1. The right to receive a printed copy of this notice.

2. The right to receive an accounting of how and to whom your protected health

information has been disclosed.

3. The right to receive confidential communications concerning your medical condition and

treatments.

4. The right to inspect and copy your protected health information.

5. The right to amend or submit corrections to your protected health information.

6. The right to request restrictions on the use and disclosure of your protected health

information.

Pegasus Pediatrics Practice Responsibilities.

We are required by law to maintain the privacy of your protected health information and to give this notice of privacy practices. We are also required to abide by the privacy policies that are outlined in this notice.

Revising Privacy Practices.

We reserve the right, as legally permitted, to amend or modify our privacy policies and practices. These changes in our policies and practices may be required because of changes in federal and state laws and regulations. Upon request, we will provide you with the revised notice at the time of your office visit. These will be applied to all protected health information we maintain.

Requests to Inspect Protected Health Information.

You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may request access to your records by contacting our receptionist or privacy official. Your request will be reviewed and will generally be approved unless there are legal or

medical reasons to deny the request.

For more information about HIPAA:

US Department of Health & Human Services

202-619-0257 Toll Free: 1-877-696-6775

Name: _________________________________________________________________

Date:_____________________________________

Sign: __________________________________________________________________