Notice of Privacy Practices for
Hershey Pediatric Center
Hershey, PA 17033 717- 533-7850
THIS NOTICE DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW TO GET ACCESS
TO THIS INFORMATION. PLEASE READ IT CAREFULLY
If you have any questions regarding
this notice, you may contact our privacy officer at:
441 E. Chocolate Ave.
I. YOUR PROTECTED HEALTH INFORMATION
Hershey Pediatric Center is required by
the federal privacy rule to maintain the privacy of your health
information that is protected by the rule, and to provide you with
notice of our legal duties and privacy practices with respect to your
protected health care information. We are required to abide by the
terms of the notice currently in effect.
Generally speaking, your protected
health information is any information that relates to your past,
present or future physical or mental health or condition, the
provision of health care to you, and individually identifies you or
reasonably can be used to identify you.
Your medical and billing records in our
practice are examples of information that usually will be regarded as
your protected health information.
II. USES AND DISCLOSURES OF YOUR
PROTECTED HEALTH INFORMATION
A. Treatment, payment, and health care
This section describes how we may use
and disclose your protected health information for treatment, payment,
and health care operations purposes. The descriptions include
examples. Not every possible use or disclosure for treatment, payment,
and health care operations purposes will be listed.
We may use and disclose
your protected health information for our treatment purposes as well
as the treatment purposes of other health care providers. Treatment
includes the provision, coordination,
or management of health care services to you by one or more health
care providers. Some other examples of treatment uses and disclosures
- We may have you sign a sign-in sheet
and will page you in the waiting room when it is time for you to go to
an examining room.
- We may leave messages on your answering machine
regarding your appointment or to request that you contact us to
discuss your test results.
- We may transport your medical records to
another of our office locations if needed.
We may use and disclose your
protected health information for our payment purposes as well as the
payment purposes of other health care providers and health plans.
Payment uses and disclosures include
activities conducted to obtain payment for the care provided to you or
so that you can obtain reimbursement for that care, for example,
submission of a claim form to your health insurer.
3. Health care options
We may use and
disclose your protected health information for our health care
operation purposes as well as certain health care operation purposes
of other health care providers and health plans. Some examples of
health care operation purposes include:
- Quality assessment and
- Health care fraud and abuse detection and
B. Uses and disclosures for other
We may use and disclose your protected health information for
other purposes. This section generally describes those purposes by
1. Individuals involved in care or
payment for care-such as a spouse, a family member, or close friend.
For example, if you have a procedure, we may discuss your physical
limitations with a family member or other individual assisting in your
care. We will not discuss your care with individuals who you have
identified on our consent to treat
form. This form identifies individuals who should not be provided with
information about your care.
2. Notification purposes - to notify a
family member, a personal representative, or another person
responsible for your care, regarding your location, general condition,
3. Required by law or law enforcement purposes - when required
by federal, state or local law. For example, we may disclose protected
health information in response to a court order or subpoena.
health activities - for example, filing communicable disease reports
with public health agencies.
5. Business associates - certain
functions of the practice performed by a business associate such as a
counseling firm, an accounting firm, or a law firm. We may disclose
protected health information to our business associates and allow them
to create and receive protected health information on our behalf. For
example, we may share with our attorney, information regarding your
care and payment for your care in the event a legal situation occurs.
C. Uses and disclosures with
For all other purposes which do not fall under a
category listed under Section II (subsections A and B), we will obtain
your written authorization to use or disclose your protected health
information. Your authorization can be revoked at any time except to
the extent that we have relied on the authorization.
III. Patient Privacy Rights
A. Further restriction on use or
You have a right to request that we further restrict use
and disclosure of your protected health information to carry out
treatment, payment, or health care operations, to someone who is
involved in your care or the payment for your care , or for
notification purposes. We are not required to agree to a request for a
To request a further restriction, you
must submit a written request to our privacy officer. The request must
tell us: (a) what information you want restricted; (b) how you want
the information restricted, and (c) to whom you want the restriction to
B. Confidential communication
a right to request that we communicate your protected health
information to you by a certain means or at a certain location. For
example, you might request that we only contact you by mail or at
work. We are not required to agree to requests for confidential
communications that are unreasonable.
To make a request for confidential
communications, you must submit a written request to our privacy
officer. The request must tell us how or where you want to be
contacted . In addition, if another individual or entity is
responsible for payment, the request must explain how payment will be
C. Accounting of disclosures
You have a
right to obtain, upon request, an "accounting" of certain
disclosures of your protected health information by us (or a business
associate for us). This right is limited to disclosures within six
years of the request and other limitations. Also in limited
circumstances we may charge you for providing the accounting. To request an accounting, you must
submit a written request to our privacy officer. The request should
designate the applicable time period.
D. Inspection and copying
You have a
right to inspect and obtain a copy of your protected health
information that we maintain in a designated records set. This right
is subject to limitations and we may impose a charge for the labor and
supplies involved in providing copies.
To exercise your right of access, you
must submit a written request to our privacy officer. The request
must: (a) describe the health information to which access is
requested, (b) state how you want to access the information, such as
inspection, pick-up of copy, mailing of copy, (c) specify any requested
form or format, such as paper copy or an electronic means, and (d)
include the mailing address if applicable.
E. Right to amendment
You have a right
to request that we amend protected health information that we maintain
about you in a designated records set if the information is incorrect
or incomplete. This right is subject to limitations. To request an
amendment, you must submit a written request to our privacy officer. The request
must specify each change that you want and provide a reason to support
each requested change.
F. Paper copy of privacy notice
have a right to receive, upon request, a paper copy of our Notice of
Privacy Practices. To obtain a paper copy, contact our privacy
IV. CHANGES TO THIS NOTICE
We reserve the right to chance this
notice at any time. We further reserve the right to make any change
effective for all protected health Information that we maintain at the
time of the change- including information that we created or received
prior to the effective date of change.
We will post a copy of our
current notice in the waiting room for the practice. At any time,
patients may review the current notice by contacting our privacy
If you believe that we have violated
your privacy rights, you may submit a complaint to the practice or the
Secretary of Health and Human Services. To file a complaint with the
practice, submit the complaint in writing to our privacy officer. We
will not retaliate against you for filing a complaint.
VI. LEGAL EFFECT OF THIS NOTICE
This notice is not intended to create
contractual or other rights independent of those created in the
federal privacy rule.