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AVON PEDIATRICS
NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about your child may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions about this Notice please contact our Privacy Contact: Sarah R..

This Notice of Privacy Practices describes how we may use and disclose your child’s protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your child’s protected health information. “Protected health information” is information about your child, including demographic information, that may identify your child and that relates to your child’s past, present or future physical or mental health or condition and related health care services.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices at the time of your next appointment.

1. Uses and Disclosures of Protected Health Information
Uses and Disclosures of Protected Health Information Based Upon Your Written Consent
You will be asked by your child’s physician to sign a consent form. Once you have consented to use and disclosure of your child’s protected health information for treatment, payment and health care operations your child’s physician will use or disclose your child’s protected health information as described in this Section 1. Your child’s protected health information may be used and disclosed by your child’s physician, our office staff and others outside of our office that are involved in your child’s care and treatment for the purpose of providing health care services to your child. Your child’s protected health information may also be used and disclosed to pay health care bills and to support the operation of the physician’s practice.
Following are examples of the types of uses and disclosures of your child’s protected health care information that the physician’s office is permitted to make once you have signed our consent form. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office once you have provided consent.

Treatment: We will use and disclose your child’s protected health information to provide, coordinate, or manage your child’s health care and any related services. This includes the coordination or management of your child’s health care with a third party that has already obtained your permission to have access to your child’s protected health information. For example, we would disclose your child’s protected health information, as necessary, to a home health agency that provides care to your child. We will also disclose protected health information to other physicians who may be treating your child when we have the necessary permission from you to disclose your child’s protected health information. For example, your child’s protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat your child.
In addition, we may disclose your child’s protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your child’s care by providing assistance with your child’s health care diagnosis or treatment to your physician.

Payment: Your child’s protected health information will be used, as needed, to obtain payment for health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for your child such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to your child for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your child’s relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

before it approves or pays for the health care services we recommend for your child such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to your child for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your child’s relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as needed, your child’s protected health information in order to support the business activities of your child’s physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, patient fundraising activities, and conducting or arranging for other business activities.
For example, we may disclose your child’s protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your child’s physician. We may also call you by name in the waiting room when your child’s physician is ready to see you. We may use or disclose your child’s protected health information, as necessary, to contact you to remind you of your child’s appointment.
We will share your child’s protected health information with third party “business associates” that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your child’s protected health information, we will have a written contract that contains terms that will protect the privacy of your child’s protected health information.

We may use or disclose your child’s protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may use your child’s name and address to send you a newsletter about our practice and the services we offer. You may contact our Privacy Contact to request that these materials not be sent to you.

Uses and Disclosures of Protected Health Information Based upon Your Written Authorization
Other uses and disclosures of your child’s protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that your child’s physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object
We may use and disclose your child’s protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your child’s protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your child’s physician may, using professional judgment, determine whether the disclosure is in your child’s best interest. In this case, only the protected health information that is relevant to your child’s health care will be disclosed.

Others Involved in Your Child’s Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your child’s protected health information that directly relates to that person’s involvement in your child’s 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 child’s best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your child’s care of your child’s location, general condition or death. Finally, we may use or disclose your child’s protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your child’s health care.

Emergencies: We may use or disclose your child’s protected health information in an emergency treatment situation. If this happens, your child’s physician shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your child’s physician or another physician in the practice is required by law to treat your child and the physician has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your child’s protected health information to treat your child.

Communication Barriers: We may use and disclose your child’s protected health information if your child’s physician or another physician in the practice attempts to obtain consent from you but is unable to do so, due to substantial communication barriers and the physician determines, using professional judgment that you intend to consent to use or disclosure under the circumstances.


Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object
We may use or disclose your child’s protected health information in the following situations without your consent or authorization. These situations include:

Required By Law: We may use or disclose your child’s protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.

Public Health: We may disclose your child’s protected health 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 your child’s protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.

Communicable Diseases: We may disclose your child’s protected health 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.

Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Abuse or Neglect: We may disclose your child’s protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your child’s protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration: We may disclose your child’s protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.

Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

Research: We may disclose your child’s protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your child’s protected health information.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your child’s protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is

necessary for law enforcement authorities to identify or apprehend an individual.

Workers’ Compensation: Your child’s protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs.

Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.


2. Your Rights
Following is a statement of your rights with respect to your child’s protected health information and a brief description of how you may exercise these rights.

You have the right to inspect and copy your child’s protected health information. This means you may inspect and obtain a copy of protected health information about your child that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your child’s physician and the practice uses for making decisions about your child.

Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewed. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Contact if you have questions about access to your child’s medical record.


You have the right to request a restriction of your child’s protected health information. This means you may ask us (in writing) not to use or disclose any part of your child’s protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your child’s protected health information not be disclosed to family members or friends who may be involved in your child’s care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your child’s physician is not required to agree to a restriction that you may request. If physician believes it is in your child’s best interest to permit use and disclosure of your child’s protected health information, your child’s protected health information will not be restricted. If your child’s physician does agree to the requested restriction, we may not use or disclose your child’s protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your child’s physician. You may request a restriction by placing your request with specifics in writing and delivering to our Privacy Contact.


You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Contact.


You may have the right to have your child’s physician amend your child’s protected health information. This means you may request an amendment of protected health information about your child in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, 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. Please contact our Privacy Contact to determine if you have questions about amending your child’s medical record.

You have the right to receive an accounting of certain disclosures we have made, if any, of your child’s protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, to family members or friends involved in your child’s care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations.

You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

3. Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your child’s privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.
You may contact our Privacy Contact, Sarah R. at
( 317) 272-7887 for further information about the complaint process.


This notice was published and becomes effective on April 14, 2003.

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7376 Business Center Dr.
Suite A
Avon, IN 46123 (map)

Phone: (317) 272-7887
Fax: (317) 272-7888

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