HIPAA Notice of Privacy Policy

SOUTHDALE PEDIATRIC ASSOCIATES, LTD.
NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

During treatment at Southdale Pediatric Associates, Ltd. doctors, nurses and other caregivers may gather information about your medical history and health. This notice describes how that information may be used and shared with others. It also explains your privacy rights regarding this kind of information. The terms of this notice apply to health information created or received by Southdale Pediatric Associates, Ltd. We are required by law to: make sure that health information that identifies you is kept private; give you this notice of our legal duties and privacy practices with respect to information about you; and follow the terms of the notice that is currently in effect.

Most patients of Southdale Pediatric Associates, Ltd. are children. When we refer to “you” or “your” in this notice, we refer to the patient. Under Minnesota law, the term “patient” also includes the patient’s guardian or other person legally authorized to receive information about the patient.

Your health information may be used and disclosed for the following purposes:

Treatment: We may use your information to provide, coordinate, and manage your care and treatment. For example, a physician treating you may share health information with another physician for consultation or a referral. We will get your written consent prior to making disclosures outside of Southdale Pediatric Associates, Ltd. for treatment purposes, except in emergency circumstances when it is not possible to get your consent.

Payment: We may use information about you to receive payment for the services we provide. For example, we will disclose information in order to submit bills or claims to insurance companies and Medicare or Medicaid. We will get your written consent prior to making disclosures for payment purposes.

Health care operations: We may use information about you for certain activities related to the functioning of Southdale Pediatric Associates, Ltd. For example, we may use or disclose your health information for quality assurance activities. We will get your written consent before making disclosures to others outside of Southdale Pediatric Associates, Ltd. for health care operations purposes.

Appointment reminders and other health information: We may use your information to send you reminders about future appointments or to provide you with information about new or alternative treatments or other health care services that may be of interest to you.

Fundraising: We may use your information to notify you about fund-raising campaigns or other charitable events.

Family members or other responsible people: We may disclose information about you to people who will be taking care of the patient or are responsible for paying bills, such as other family members. Southdale Pediatric Associates, Ltd. will only disclose health information that these people need to know. We may also use information to let other family members or other responsible people know about your general medical condition or where you are located. If the patient is able to make his or her own health care decisions, Southdale Pediatric Associates, Ltd. will ask permission before using health information for these purposes. If the patient is unable to make health care decisions, Southdale Pediatric Associates, Ltd. will disclose relevant health information to family members or other responsible people if we feel it is in the patient’s best interest to do so. For example, we may provide limited health information to allow another family member to pick up a prescription or X-ray for the patient.

Emergency conditions: Under emergency conditions, we will disclose information about you to the government or other groups that assist in emergencies or disasters only as required by law or with your written consent.

To Business Associates: Some services are provided by or to Southdale Pediatric Associates, Ltd. through contracts with business associates. Examples include our attorneys, consultants, collection agencies, and accreditation organizations. We may disclose information about you to our business associate so that they can perform the job we have contracted with them to do. To protect the information that is disclosed, each business associate is required to sign an agreement to appropriately safeguard the information and not to redisclose the information unless specifically permitted by law.

Other uses or disclosures: Southdale Pediatric Associates, Ltd. may disclose or use information in the following cases, either with your written consent or to the extent permitted or required by law: for public health activities; relating to victims of abuse, neglect, or domestic violence; for health oversight activities; for judicial and administrative proceedings; for law enforcement purposes; to coroners, medical examiners, and funeral directors; for organ donation purposes; for research purposes under certain circumstances; to avert a serious threat to health or safety; for certain specialized government functions, such as military discharge and national security and intelligence; for workers compensation purposes; and in other circumstances when required by law.

Research: Federal law permits Southdale Pediatric Associates, Ltd. to use and disclose health information about you for research purposes, either with your specific, written authorization or when the study has been reviewed for privacy protection by an Institutional Review Board or Privacy Board before the research begins. In some cases, researchers may be permitted to use information in a limited way to determine whether the study or the potential participants are appropriate. Minnesota law generally requires that we get your general consent before we disclose your health information to an outside researcher. We will make a good faith effort to obtain your consent or refusal to participate in any research study, as required by law, prior to releasing any identifiable information about you to outside researchers.

Except as described above, Southdale Pediatric Associates, Ltd. will not use or disclose your protected health information without a specific written authorization from you. If you provide us with this written authorization to use or disclose health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by your written authorization, except to the extent we have already relied on your authorization. We are unable to take back any disclosures we have already made with your permission, and we are required to retain our records of the care that we provided to you.

You have the following rights regarding health information we maintain about you:

Restrict use and disclosure: You may request that Southdale Pediatric Associates, Ltd. not use health information in certain ways or for certain purposes. You may also request that Southdale Pediatric Associates, Ltd. not provide health information to certain people. If you pay out-of-pocket in full for an item or service, then you may request that we not disclose information pertaining solely to such item or service to your health plan for purposes of payment or health care operations. We are required to agree with such a request. However, we are not required to agree to any other request.

Provide confidentiality: You may request that Southdale Pediatric Associates, Ltd. provide you with your health information in a confidential manner. For example, you can request that we send appointment reminders, bills, and other mailings to a different address or that we notify you of this kind of information in another way, such as by telephone call. You must make this request in writing and specify another address or means of communication. We will not ask you the reason for your request. We will accommodate all reasonable requests. We may also ask you to give us information about how you will pay your bills.

Inspect and copy: You may ask to see and copy your medical records, unless that information is protected by law. You must make these requests in writing. If your request to look at or copy the patient’s medical records is denied, you have the right to have the denial reviewed by a health care professional. We will act upon your request within 30 days and may charge you a legally acceptable amount for copying costs.

Change information or amend medical records: You may ask us to amend information in the patient’s medical records. If your request is denied, you can write a statement of disagreement with the denial that we will keep with your health information.

Request accounting of disclosures: You may ask us to provide you with information about certain disclosures of your health information we made in the past. You may request an accounting of disclosures made in the past six years, but this accounting will only cover disclosures made after April 14, 2003.

Request paper copy: If you have received this notice of the health information privacy rights electronically, you may ask us to provide you with a paper copy.

Complaints or questions: If you feel your health information privacy rights have been violated, you may file a complaint with the Secretary of Health and Human Services and/or with Southdale Pediatric Associates, Ltd. privacy official listed below. Filing a complaint will not affect the quality of the services you receive from Southdale Pediatric Associates, Ltd. and you will not be retaliated against for filing a complaint: The U.S Department of Health and Human Services 200 Independence Avenue S.W. Washington, D.C. 20201 (202) 619-0257 Toll free: 1 (877) 696-6775 Electronic: HHS.Mail@hhs.gov

Southdale Pediatric Associates, Ltd. privacy official: You may contact the designated privacy official:

Southdale Pediatric Associates, Ltd.
Privacy Official
3955 Parklawn Avenue-Suite 120
Edina, MN 55435
(952) 831-1944

Effective Date: The effective date of this notice is April 14, 2003. Southdale Pediatric Associates, Ltd. is required by law to maintain the privacy of protected health information and to provide individuals with this notice of its legal duties and privacy practices with respect to health information. Southdale Pediatric Associates, Ltd. is required to abide by the terms of the notice currently in effect. Southdale Pediatric Associates, Ltd. reserves the right to change the terms of this notice and to make new notice provisions effective for all protected health information maintained by Southdale Pediatric Associates, Ltd. If the terms of this notice are changed, Southdale Pediatric Associates, Ltd. will provide individuals with a revised notice: at the time of treatment, or upon request, by posting the revised notice in designated office locations at Southdale Pediatric Associates, Ltd. and on the web site: www.southdalepeds.com.

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