Policies

Office Policies:

Dear Parents,

Welcome to New Brunswick Pediatric Group. It is our privilege and an honor to have the opportunity to provide you with the best possible care available. In order to conform to the insurance regulations and keep our costs competitive, we kindly request you to comply with the followings.

As a Physician, me and my staff would like to be OPEN and HONEST with all our patients and parents from the beginning, and build Doctor-Patient relation on a solid ground. Over the past 14 years from interactions with multiple personalities and nature of insurance companies, we have concluded the following guidelines. We welcome your family and would be an honor to have you as our patients. We hope that you would also understand and comply to build the relation in the best of your children’s future care. We appreciate your trust in us. Please keep in mind, our goal is for well being and best possible care of our patients. That being said……….

For New patients few points in brief:

Vaccination is never given during your first visit.
To provide coordinated care to our patients, we request that we remain pediatrician for all of your children.
Sports Physical will not be done on your first visit.
Do not schedule appointment for just a second opinion.
Since we need to have comprehensive knowledge of our patient’s health, we do not accept temporary patients.
Please make payments in cash ONLY (one that requires patient’s responsibilities)

Insurance Nuisance:

For Referrals: In the event that your insurance plan requires you to have a referral:

¨      It is up to the physician to decide whether you need a referral or not. If you have a HMO/managed care plan, most insurance companies require us to treat you up to a reasonable extent in our reach.

¨      Kindly give us 3 or more business days to prepare referral.

¨      If your insurance company delays/denies the referral, we will not be responsible for any inconvenience/expenses.

¨      We are unable to issue backdated referrals.

¨      Please pick up your referral from our office a few days before your visit with a specialist.

It is your responsibility to be fully familiar with your insurance coverage and benefits. Due to varying insurance company requirements, we cannot be responsible for referring you to a facility not covered by your insurance company (For Example: for blood work, x-ray, specialist or other paramedical specialty). Prior visiting to any facility or doctor for further work up or treatment, please confirm with your insurance or related facility.

For eyeglass check or recheck, please check with your insurance if you have vision plan benefit, and if you do, follow your insurance guidelines.

Office Policy:

We do not fax any kind of medical documents anywhere.

Due to the nature of the examination involved, sports forms will require a special physical which is a separate visit from a regular check-up. Therefore, please make a separate appointment with us for such needs. We may not be able to provide sports physical on a new patients due to the short time frame of our association with you.

Due to coordination of care issues, we will be unable to provide our services to patients going to multiple doctors without our knowledge or prior discussion.

As a courtesy, we make reminder phone calls the day before an appointment. However, it is parent’s responsibility to remember appointment and be on time.

Most likely, a sick child is seen on the same day. If your child is ill, please call us between 10:00 to 10.30 am on week days and 8.00 to 8.30 am on Saturdays to make an appointment for an office visit. We are unable to guarantee the time or office locationof your choice for same day appointments, as we are available for half a day at each of our two offices. Also, please be considerate to our other patients and be on time, so that they do not have to wait.

On Sundays and Holidays, if your child is sick, please call us at 8:00 am. If possible, we will try our best to accommodate your child to be seen on the same day. If your child appears to be falling ill before a weekend, please call us on Friday or at the latest by Saturday morning to make an appointment for an office visit. Please do not wait till Saturday afternoon or Sunday. Once the office is closed for the weekend, the medical care would be delayed or you have to spend your precious time in the emergency room.

We understand that some of our patients have both working parents and would like the last appointment for the day. Kindly schedule these appointments in advance. Patients who have scheduled these appointments in advance will have priority. Our office staff will strive to be flexible, but we do appreciate your understanding the constraints involved in scheduling.

Saturdays are generally very busy regarding appointments, and we realize how important the time is for you on weekend. We try our best to see your child quickly and precisely, this can be accomplished if only all the patients come on time. Therefore, please be on time and do not cancel your appointment at last minute. If you think you need more time to discuss your child’s health, than please schedule appointment during weekdays morning/early afternoon. This will give us both sufficient time to spend and discuss.

As a courtesy to our parents we will fill out one form or vaccination records per year FREE of charge. Requests for completions of any forms, reports or other paperwork may require up to 3 or more business days and a fee of $ 10 or more per form, paid in advance, proportional to the amount of the preparation involved. Kindly realize that filling out forms is never an emergency. We request you not to hold onto forms and rush to have them completed at the last minute. Schools and other educational/recreational facilities do give forms sufficiently in advance so that doctors have adequate time to complete them. Certain forms may require a visit to our office.

When child is sick, please call as early as possible as the office opens (10:00 am).According the sickness, we can see your child as soon as possible. After hours phone calls are generally for emergency cases ONLY. Please be very discrete about it. If child is sick all day, DO NOT wait till nightfall to call us. When you call us day/night and if we suggest that your child needs to be seen, we will guide you when and where you should bring the child for an evaluation. After the telephone advice during night or weekend, we would like to see your child in the next available office appointment. Please bring them to the office for an evaluation even if they appear to recover from the illness. Many times the follow up examination alters the course of medical advice. If you are advised for follow-up visit to office for any particular reason, please make sure you schedule that appointment. Non compliance in this may result in suboptimal care for your child. We strive to provide the best possible care for your child. A conflict in this matter may force us to ask you to look for another physician.

Well-Care and Sick-Care visits should NOT be combined in any situation. If your child has a health issue, please schedule an appointment separate from that of the well check up. Please DO NOT wait until next regular check-up visit to discuss about your child’s health issue. When in doubt, call at our office, we will be more than happy to give you an advice. If problems arise at the regular visit, we might ask you to reschedule well check-up visit or schedule an appointment for evaluating the problem that we just discovered. We like to discuss certain problem at length and explain to parents their option for treatment.

We strongly recommend age appropriate regular check-ups for all our patients. We will inform you at the regular visit when your next appointment should be. Please make that appointment well in advance before leaving our office, so you could get the time slot that is convenient for you. This also helps as you do not need to worry about remembering to make that next appointment. Please do not call us at the last minute and try to squeeze an appointment for your child. Time to time, we give you a call or mail you a letter reminding you to schedule a well care visit. After few reminders, if you fail to make the regular check-up appointment, we may ask you to choose another doctor for future care. Vaccination is not the only reason children should be brought in for regular check-ups. We monitor for different age appropriate developmental milestones and growth parameters during each well check-up visit. That is also the time to find out about problems with vision, hearing, blood pressure, etc.

We request you to schedule well care / shots visits for children 4 years and older, during the months of May to August as they tend to be healthier during that period. Also, if well check up is completed, any required school forms and sports physicals can be filled without delay. Between Sept.15th and Nov.15 our office would be busy administering flu shots administering flu-shots. We do not give any well-care appointments during this time for this age group. Once the school starts, you may not want to take your child out from the school for the well check-up. Moreover, we have very limited slots available during after-school hours. Once the winter starts, the school-going children tend to get sick more often, and therefore, it would be difficult to schedule for well check-ups.

Please do not ask our office staff or call inquiring about which shots or vaccinations will be given at next visit. Our office staff is not trained to make that decision. Even though we follow the schedule recommended by the American Academy of Pediatrics, we individualize the immunization schedule to the needs of your child. As each child is different with his or her own unique requirements. We would make the recommendation at the time of the visit based on the examination.

Ear cleaning is considered as a surgical procedure from the insurance point of view. Most insurance do not reimburse ear cleaning with regular appointment. So if needed, we may ask you to schedule a separate appointment for that procedure. It is very painful for your child if ear cleaning has to be done when he or she has an ear infection. In order to effectively care for your children, we urge you to bring them to the office so that the ears can be cleaned with minimal discomfort.

We strongly recommend all our new patients to bring patients medical records including vaccination records in proper form from previous physician’s office. We do not accept regular vaccination cards as proof of record as some of them are not properly updated. For any new patients coming to our office, we do not give vaccination at their first visit as it takes some time for us to go through their records and figure out what exactly they require.

To provide coordinated care to our patients, we request that we remain pediatrician for all children in the same family. There are many inherited genetic conditions that could affect the siblings and also many infectious diseases spread among the family members. It is better not to give fragmented care for our patients and their family. For the same reason, we do not accept temporary patients. If you do not agree with this office policy, please do not schedule an appointment.

We accept new patients and love to take care of your children as our patients. But, we do not give second opinion for any reason. Most of the chronic or serious problems do require multiple visits and might take some time to diagnose and manage. It is in the best interest of your child to continue with one physician who takes care of these issues until resolved. Doctor shopping may not only resolve issues but might lead to further complications. Only time and faith in your current doctor will be the best policy.

If you need copy of any medical records or document for your own need, there is a charge $ 1.00 per page for photocopying medical records or documents. (Permitted by NJ department of health.)

As a courtesy to our patients who needs to change their physician, we will provide afree signed medical record summary for one time ONLY. We need a written request and a minimum of seven working days or more to review the charts and prepare the medical record summary. You are expected to pick up the record summary as we do not mail or fax it. If for any reason, you cannot pick it up in person, you may make arrangements to have it sent to you via UPS/Fed-ex by providing us with a prepaid envelope. We advise you to make a copy of the record summary for yourselves before giving the original to your new physician. If for some reason, you need the record summary again, there is a charge of $50.00. There is also a charge of $75.00 to provide records for any insurance company (such as a life insurance or disability insurance) that requires medical records.
Prescriptions are never called over the phone. Please make sure that you have sufficient supply of maintenance medications that your child needs. Please DO NOT wait till weekend or when office is closed. If you are running out of them and you do not have any refills left, please call the office during regular office hours and make an appointment.

Please notify our office of any changes to your insurance, cell/home/work phone number, email address, home address or other related important information.

We strive to resolve any differences that may occasionally arise between you and our office. For irreconcilable differences, we may ask you to choose another physician for your child’s future medical care. We will inform you verbally and/or in writing. In situation, we will provide ONLY emergency medical care (not routine well care or shots) for the next 30 days.

We request you to remove “call block” from your phone number which you expect a phone call back. Doctor’s number will be private when he/she returns your call. In which case you may not know that the physician is calling you back. Doctor might not be able to get through and will not be responsible for any delay in treatment/inconvenience if there is a call block. You can remove call block for private number from your phone by dialing *87. We also request that you keep your telephone line open, if you are waiting for a call back from doctor.

Patients are only seen with appointments. We strongly request no walk-in patients please. If you are running late please call us. If you come more than 20 minutes late,sometimes we may have to reschedule your appointment or you may have to wait for the next available slot.

As a courtesy to you, we are willing to provide care for sick children of your friends or relatives visiting New Jersey. In such cases, we collect the fees for the examination at the time of the visit and later refund it if and when their insurance reimburses our office.
Following Guidelines
Physicians must follow accepted national guidelines when determining what your charges (level of service) will be. They must code your visit based upon what services were provided and cannot take into account particular health plan benefit designs. Consequently we are unable to switch the visit reason and diagnosis in order for a claim to be covered by your insurance. If you think there is an error on your account, please contact the office immediately. We will review your concern with the physician and let you know the outcome.
Newborns
You should contact your insurance company as soon as possible after your child has been born. Most health plans allow 30 days to add your newborn to your insurance plan. In state of the new Jersey, baby is covered under mother’s plan for four weeks. If you are unable to provide proof of insurance after your baby’s four week appointment, we will charge you in full for services rendered.
Circumcision

We do not do circumcision. Circumcisions are NOT recommended by AmericanAcademy of Pediatrics, but it can be done by your Ob-gyn dr at your request at time of birth.

Ear piercing

We do pierce ears of small baby. We recommend to get it done between 4 to 6 months of age. As it is purely for personal reason, insurance DO NOT pay for it and will require separate visit.

Waiting Room
We request, when possible, that you limit the number of children, friends, and relatives accompanying your child to the office. We understand, of course, that on occasion babysitting or transportation problems may leave you no choice. It should be noted that there have been no studies documenting the need for, or benefit of, separate waiting rooms for well and sick children. We make an effort to limit the transmission of illnesses by reducing the amount of time children spend in our waiting room.

Financial Policy:

1.     We are committed to providing the best treatment for our patients and charge what is usual and customary in our area. We take our responsibility with utmost seriousness and would appreciate prompt payment for our services. Patients are responsible for payments regardless of their insurance company’s arbitrary determination of usual and customary rates.

2.     We will provide you with a receipt for all your payments at the time of your visit. Kindly keep this receipt in safe custody as we may not be able to provide you with another receipt or copies of statements at a later date.

3.     Under certain special circumstances, you may be requested to pay at the time of your visit, regardless of the kind of your insurance. For Circumstances include (i) not having a proper Insurance ID card with doctor’s and patient’s name(s) on it, (ii) we cannot confirm your coverage with your insurance company at the time of your visit (i.e. in evenings, weekends, holidays or inability to contact your insurance company). We will promptly refund you once after your insurance reimburses our office.

4.     Regarding Managed Care Insurance in which we participate: Please supply our office staff with your primary and secondary insurance identification card(s) at the time of your appointment. If your insurance requires co-pay or deductible, kindly pay it, at the time of the appointment.

5.     There are certain instances under which we request you to be responsible for the payments. For example, incorrect insurance information provided at the time of your visit might lead to a delay in filing a claim with your insurance company. If your insurance company fails to compensate us for services rendered for any reason, payment will be your responsibility.

6.     At times your insurance carrier may deny payment for authorized services. If so, you may be requested to help resolve these issues with your carrier.

7.     Regarding Non-Participating Insurances: We do our utmost best to be a participating provider for a wide range of insurance companies. In the event that we do not participate with your insurance, bill payment at the time of service is your responsibility. Please kindly recognize that your insurance policy is a contract between you and your insurance company and our office is not part of that contract.

8.     Due to disruptions associated with cancellation of appointment, there is a nominal$35.00 fee associated when canceled less than a 24-hour notice. Parents with repeated missed/delayed appointment will be asked to choose another physician for future care of their children,

9.  Payment must be received by the due date. A late fee of up to $ 50.00 will be charged after patient/parent is notified in person, by mail or phone for each visit.

Any account that is due over 14 days without payment is subject to immediate collection process. Accounts that sent out side agency/attorney for collection will be subjected to 35% additional charge plus attorney’s fees. After one year additional charge will be 45% plus attorney’s fees.

10.  A charge of $35.00 will be collected for any bank return check, along with the previous balance.

11.  We require social security number from both the parents and government issued proof of identification with photo. No exception is given to any one regarding this policy. Just because you have insurance, insurance company do not give us guarantee of payment. We take your privacy very seriously and do not share social security numbers with any outside agency/person except for collection purpose.We do not require social security numbers if you plan to pay in cash at the time of your visit each time.

12.  We are contractually required to collect co-pay at the time of service. If you do not pay your co-pay at the time of service, you will be charged an additional         $10.00. We make no exception to this policy.

13.   If you are not sure of your covered benefits i.e. well Child visits, it is your responsibility to contact your insurance company or employer benefit office.

14.  We understand difficulties involve in divorce and court orders. However we do not participate in dispute between divorced parents. Co-pay/deductibles will be collected from parent bringing child to the office at the time of visit.

      If you are uninsured, or if we are unable to verify coverage, we will require a payment at your visit.

And Finally…………..

Current policy or changes will be posted in our office. If there are any changes to the policy, it will be updated from time to time.

Traveling Abroad:

For small children, make sure you complete all other required shots before leaving country.

Try to drink only boiled or sterilized water.

Do you know you should get these shots if you are traveling to most of the tropical countries?

Tetanus

For children less than 10 years - if interval from last shot is more than 5 yr., you need booster again.
For children > 10 yr. & adults you need booster every 10 yr.

Hepatitis - B

Everyone traveling should receive at least 3 doses of this vaccine over 6 months.
Disease is caused by virus and can spread by body secretions or blood products.
Hepatitis-B usually affects liver and in some cases lead to death.
Other symptoms like loss of appetite, tiredness, nausea, vomiting & JAUNDICE can occur.
In long term, it can cause liver cancer and/or failure.
Once patient acquires disease, there is no treatment.
Vaccine is relatively very safe and 85% - 95% effective

Hepatitis - A

Disease is caused by Hepatitis-A virus & spread by contaminated water, food & blood.
Older people are affected more severely than children.
Main symptom is JAUNDICE, but fever, nausea, vomiting, and diarrhea can occur.
Once patient acquires disease, there is no treatment.
Vaccine is relatively very safe & 95% - 100% effective.
Children and adult require 2 doses over 6 months.

Typhoid

Disease is caused by bacteria & spread by contaminated water, food & blood.
Patient may have fever, nausea, vomiting, and diarrhea. It can affect any body organ, some people remains clinically infected for rest of their life.
If detected in early stage disease is treatable without severe consequences.
Vaccine is 90-95 % effective & relatively safe. One dose is needed. Booster every 2 Yr.

Malaria

Disease is spread by mosquito & can be lethal.
No vaccine available so far.
You can take PROPHYLACTIC (To prevent disease) medicine.
Medicine should be taken two weeks prior to leaving the U.S. & should be continued 4 week after return to U.S. Ask your Dr. to prescribe medicine that work against Resistant Malarial Parasite.

OTHER

Read the newspaper, if there is an epidemic of Meningococcal Meningitis, vaccine is available for it.
Stay away from dogs or other wild animals. Newer vaccine for RABIES is available in India.
For anyone who never had CHICKEN POX or MEASELS, MUMPS & RUBELLA (MMR), you should take these vaccines.
People visiting some part of South America & Africa should take Yellow Fever vaccine.

Adoption Policies:

Pre-adoption Consultation:

Dr. Patel offers pre-adoption consultation services. We meet with families in the office to review and discuss adoption records for potential or confirmed adoptions. We also review with adoptive parents what to expect from a medical perspective once they bring their child home. We discuss in detail necessary lab work, recommended immunizations, and developmental follow-up. Please be aware that these consultations are not covered by insurance. Please contact us for further information.

Post-adoption Consultation:

Dr. Patel offers health services for families that have adopted a child internationally. After a family has arrived home with their new child, Dr Patel recommends that the child be seen in the office for an international adoption visit within two weeks. We have a specific protocol in place to evaluate these very special children with regard to lab work, immunizations, and developmental follow-up. We look forward to partnering with you in caring for your child!

NOTICE OF PRIVACY PRACTICES

As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability
and Accountability Act of 1996 (HIPAA)
Effective Date of this Notice: 04-13-2003

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.

A. OUR COMMITMENT TO YOUR PRIVACY

Our practice is dedicated to maintaining the privacy of you/your childrens individually identifiable health information. (Please note that where ever we mention you in this document, it might apply to your child if your child is our patient and not parent) In conducting our business, we will create records regarding you and the treatment and services we provide to you.

We are required by law to maintain the confidentiality of health information that identifies you.
We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your IIHI.
By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:

How we may use and disclose your IIHI
Your privacy rights in your IIHI
Our obligations concerning the use and disclosure of your IIHI

The terms of this notice apply to all records containing your IIHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times.

B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT AT:

Himanshu A. Patel, MD
Central Jersey Pediatrics, PC
1527 RT 27 South, Suite, 1600
Somerset, NJ 08873-3979

C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS
The following categories describe the different ways in which we may use and disclose your IIHI.

1. Treatment. Our practice may use your IIHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your IIHI in order to write a prescription for you, or we might disclose your IIHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice including, but not limited to, our doctors and nurses may use or disclose your IIHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your IIHI to others who may assist in your care, such as your spouse, children or parents.

Finally, we may also disclose your IIHI to other health care providers for purposes related to your treatment.

2. Payment. Our practice may use and disclose your IIHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your IIHI to obtain payment from/through third parties that may be responsible for such costs, such as family members or collection agency. Also, we may use your IIHI to bill you directly for services and items. We may disclose your IIHI to other health care providers and entities to assist in their billing and collection efforts.

3. Health Care Operations. Our practice may use and disclose your IIHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your IIHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your IIHI to other health care providers and entities to assist in their health care operations.

4. Appointment Reminders. Our practice may use and disclose your IIHI to contact you and remind you of an appointment.

5. Treatment Options .Our practice may use and disclose your IIHI to inform you of potential treatment options or alternatives.

6. Health-Related Benefits and Services. Our practice may use and disclose your IIHI to inform you of health-related benefits or services that may be of interest to you.

7. Release of Information to Family/Friends. Our practice may release your IIHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child to the pediatrician's office for treatment of a cold. In this example, the babysitter may have access to this child's medical information up to a reasonable level.

8. Disclosures Required By Law. Our practice will use and disclose your IIHI when we are required to do so by federal, state or local law.

9. For your safety: We do not fax any medical records. We advice you to pick-up your records from our office, as we do not mail or fax it. We do not call for any prescriptions over the phone.

D. USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL CIRCUMSTANCES
The following categories describe unique scenarios in which we may use or disclose your identifiable health information:

Public Health Risks. Our practice may disclose your IIHI to public health authorities that are authorized by law to collect information for the purpose of:

Maintaining vital records, such as births and deaths, reporting child abuse or neglect.
Preventing or controlling disease, injury or disability.
Notifying a person regarding potential exposure to a communicable disease.
Notifying a person regarding a potential risk for spreading or contracting a disease or condition.
]Reporting reactions to drugs or problems with products or devices.
]Notifying individuals if a product or device they may be using has been recalled.
Notifying appropriate government agency (ies) and authority ( ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information
Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

2. Health Oversight Activities. Our practice may disclose your IIHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

3. Lawsuits and Similar Proceedings. Our practice may use and disclose your IIHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding.

We also may disclose your IIHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

4. Law Enforcement. We may release IIHI if asked to do so by law enforcement official:

Regarding a crime victim in certain situations, if we are unable to obtain the person's agreement
Concerning a death we believe has resulted from criminal conduct
Regarding criminal conduct at our offices
In response to a warrant, summons, court order, subpoena or similar legal process
To identify/locate a suspect, material witness, fugitive or missing person
In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator

5. Deceased Patients. Our practice may release IIHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.

6. Organ and Tissue Donation. Our practice may release your IIHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.

7. Research. Our practice may use and disclose your IIHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your IIHI for research purposes except when an Internal Review Board or Privacy Board has determined that the waiver of your authorization satisfies the following:

(i) The use or disclosure involves no more than a minimal risk to your privacy based on the following:

(A) An adequate plan to protect the identifiers from improper use and disclosure;

(B) An adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and

(C) Adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted;

(ii) The research could not practicably be conducted without the waiver; and

(iii) The research could not practicably be conducted without access to and use of the PHI.

8. Serious Threats to Health or Safety. Our practice may use and disclose your IIHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

9. Military. Our practice may disclose your IIHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

10. National Security. Our practice may disclose your IIHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your IIHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

11. Inmates. Our practice may disclose your IIHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.

Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.

12. Workers' Compensation. Our practice may release your IIHI for workers' compensation and similar programs.

E. YOUR RIGHTS REGARDING YOUR IIHI
You have the following rights regarding the IIHI that we maintain about you:

1. Parents and Minor: We can use "discretion" to provide or deny a parent access to a minor's records as long as that decision is consistent with state law.

2. Confidential Communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to us at our official address specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.

3. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your IIHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your IIHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your IIHI, you must make your request in writing to us at our official address. Your request must describe in a clear and concise fashion:

(a) The information you wish restricted

(b) Whether you are requesting to limit our practice's use, disclosure or both; and

(c) To whom you want the limits to apply.

4. Inspection and Copies. You have the right to inspect and obtain a copy of the IIHI that maybe used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to us at our official address 30 days in advance in order to inspect and/or obtain a copy of your IIHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.

5. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment (Not alteration) as long as the information is kept by our practice. To request an amendment, your request must be made in writing and submitted to us at our official address.

You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the IIHI kept by or for the practice; (c) not part of the IIHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.

6. Accounting of Disclosures. All of our patients have the right to request an "accounting of disclosures". An "accounting of disclosures" is a list of certain non-routine disclosures our practice has made of your IIHI for non-treatment, non-payment or non-operations purposes. Use of your IIHI as part of the routine patient care (TPO) in our practice is not required to be documented.

For example, the doctor shares information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to us at our official address.

All requests for an "accounting of disclosures" must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

7. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices one time. You may ask us to give you a copy of this notice again with charge.

8. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact us at our official address. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

9. Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your IIHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your IIHI for the reasons described in the authorization. Please note that we are required to retain records of your care.

Again, if you have any questions regarding this notice or our health information privacy policies, please contact us at our official address.