This notice describes how protected medical and drug-related information about you may be used and disclosed and how you can
get access to this information. Please review it carefully.
Information regarding your health care, including payment for health care and treatment, is primarily protected by three federal laws:
(i) the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. § 1320d et seq., 45 C.F.R. Parts 160 & 164; (ii)
the additional privacy and security requirements enacted pursuant to Subtitle D of the Health Information Technology for Clinical
Health Act (HITECH), including 45 C.F.R. Sections 164.308, 164.310, 164.312, and 164.316; and (iii) the Confidentiality Law, 42
U.S.C. § 290dd-2, 42 C.F.R. Part 2. Under these laws, Pediatricians of Hyde Park, LLC may not say to a person outside
Pediatricians of Hyde Park, LLC that you are a patient, nor may Pediatricians of Hyde Park, LLC disclose any information identifying
you or disclose any other protected information about you, except as permitted by federal or Ohio law.
How Pediatricians of Hyde Park, LLC May Use and Disclose Medical Information about You
The following list describes the ways Pediatricians of Hyde Park, LLC may use and disclose your medical information without your written authorization. The examples provided serve only as guidance and do not include every possible use or disclosure.
For Treatment: We may use and disclose your Protected Health Information to provide, coordinate, or manage your health care and any related service. For example, we may disclose your PHI to other doctors who need the information to provide you with care.
For Payment: We may use and disclose medical information about you so that the treatment and services you receive may be billed
and payment may be collected from you, an insurance company, or a third party. We may also tell your health plan about a
treatment or procedure you are going to receive in order to obtain prior approval or to determine whether your plan will cover the
For Health Care Operations: We may use and disclose medical information about you for our operations. For example, we may
use your PHI to assess our treatment and services. These uses and disclosures are necessary to operate Pediatricians of Hyde
Park, LLC in an efficient manner and to ensure that all individuals receive quality care.
Treatment Reminders: We may use and disclose medical information in order to remind you of a scheduled treatment appointment
Business Associates: We may disclose your PHI to persons who perform functions, activities or services to us or on our behalf that require the use or disclosure of PHI. To protect your health information, we require the business associate to appropriately safeguard your information.
Required by Law: We will disclose medical information about you when required to do so by federal or Ohio state laws.
To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you to medical or law
enforcement personnel when necessary to prevent a serious threat to your health and safety or the health and safety of the public or
Sale of Pediatricians of Hyde Park, LLC: We may use and disclose medical information about you to another health care entity in
the sale, transfer, merger, or consolidation of Pediatricians of Hyde Park, LLC, unless your medical information includes information
about substance use disorder treatment services provided to you. Such information will only be transferred to the new entity
pursuant to your written authorization as further described below.
Electronic Disclosure: We may disclose your medical information orally, in paper format or through the use of any electronic
Organ and Tissue Donation: If you are an organ donor, we may disclose your PHI to organizations that handle procurement of
organ, eye, or tissue transplantations
Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by
military command authorities.
Workers’ Compensation: We may release medical information about you for workers’ compensation or similar programs. These
programs provide benefits for work-related injuries or illness.
Qualified Personnel: We may disclose medical information for research or for management audit, financial audit, or program
evaluation, but Pediatricians of Hyde Park, LLC personnel may not directly or indirectly identify you in any report of the research,
audit, or evaluation, or otherwise disclose your identity in any manner.
Public Health Risks: We may disclose medical information about you for public health activities. These activities generally include the following:
- To prevent or control disease, injury, or disability;
- To report births and deaths;
- To report child abuse or neglect;
- To report reactions to medications or problems with products;
- To notify people of recalls of products they may be using;
- To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
- To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.
All such disclosures will be made in accordance with the requirements of federal and Ohio state laws and regulations.
Health Oversight Activities: We may disclose medical information to a health oversight agency for activities authorized by
law. Health oversight agencies include public and private agencies authorized by law to oversee health care providers and the
health care industry in general.
Law Enforcement: We may disclose your PHI, so long as applicable legal requirements are met, for law enforcement purposes,
such as providing information to the police about the victim of a crime.
Coroners, Medical Examiners, and Funeral Directors: We may release medical information to a coroner or medical examiner
when authorized by law (e.g., identify a deceased person or determine cause of death) or to funeral directors.
Inmates: If you are an inmate of a correctional facility or under the custody of a law enforcement official, we may release health and
treatment information about you to the correctional facility or law enforcement official. Such release would be necessary for: (1) the
facility to provide you with proper care; (2) to protect your health and safety or the health and safety of others; and (3) to ensure the
safety and security of the correctional facility.
Other Uses and Disclosures
Pediatricians of Hyde Park, LLC will not use or disclose your medical information for any other purposes (including, without limitation, marketing), unless you give Pediatricians of Hyde Park, LLC your written authorization to do so. If you give Pediatricians of Hyde Park, LLC such written authorization for a purpose not described in this Notice, then you may, in most cases, revoke such authorization in writing at any time. Your revocation will be effective for all your medical information Pediatricians of Hyde Park, LLC maintains, unless our practice has already taken action in reliance on your prior authorization.
Substance Use Disorder Treatment: Your medical information related to such services is protected by federal law and regulation
(see 42 CFR Part 2) and will only be used or disclosed by Pediatricians of Hyde Park, LLC pursuant to: (1) your written authorization;
(2) a court order or other legal requirement; (3) medical needs in an emergency to qualified medical personnel; or (4) research, audit,
or program evaluation purposes to qualified personnel. This includes use or disclosure of such information in the event of a sale,
transfer, merger, or consolidation of Pediatricians of Hyde Park, LLC. If you do not provide written authorization in such an event,
your information will not be transferred.
Please note that federal law or Ohio regulations protecting alcohol or drug treatment records do not protect any information about a
crime committed by a patient of Pediatricians of Hyde Park, LLC or a member of our practice workforce, or any information about
suspected child abuse or neglect that is otherwise reportable under Ohio law to appropriate state or local authorities. A violation of
the federal law and regulations that protect the confidentiality of substance use disorder treatment patient records is a
crime. Suspected violations may be reported to appropriate authorities in accordance with 42 CFR Part 2.
Your Health Information Rights
Right to Inspect and Copy: You have the right to inspect and obtain a paper or electronic copy of medical information that may be
used to make decisions about your care, except for information compiled for use in a civil, criminal, or administrative proceeding or in
other limited circumstances.
To inspect and copy your medical information, you must submit your request in writing to the Pediatricians of Hyde Park, LLC
Compliance Officer. If you request a copy of the information, our practice may charge a fee as established by its licensing authority,
if applicable, for the costs of copying, mailing, or summarizing your medical records.
Pediatricians of Hyde Park, LLC may deny your request to inspect and copy your medical information in certain very limited
circumstances. If you are denied access to medical information, you may request that the denial be reviewed. A third-party licensed
health care professional chosen by Pediatricians of Hyde Park, LLC will review your request and denial. This professional will not be
the same person who denied your request. Our practice will comply with the outcome of the review.
Right to Amend: If you feel that medical information maintained about you is incorrect or incomplete, you may ask your provider to
correct or amend the information. You have the right to request an amendment for as long as the information is kept by Pediatricians
of Hyde Park, LLC.
To request an amendment, your request must be made in writing and submitted to the Pediatricians of Hyde Park, LLC Compliance
Officer. In addition, you must provide a reason that supports your request. Our provider may deny your request for an amendment if
it is not in writing or does not include a reason to support the request.
Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a list of the
disclosures made of your medical information for purposes other than treatment, payment, or health care operations.
To request this list, you must submit your request in writing to the Pediatricians of Hyde Park, LLC Compliance Officer. Your request
must state a time period, which may not be longer than six (6) years. Your request should indicate in what form you want the list (for
example, on paper or electronically). The first list you request within a 12-month period will be provided to you by our practice for
free. For additional lists within the 12-month period, you may be charged for the cost of providing the list. Our practice will notify you
of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information Pediatricians of
Hyde Park, LLC uses or discloses about you for treatment, payment, or health care operations. You also have the right to request a
limit on the medical information our practice uses or discloses about you to someone who is involved in your care or the payment for
your care. Our practice is not required to agree to such a request. Should our practice agree to your request, we will comply with
your request unless the information is needed to provide you with emergency treatment.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information with your health insurer
for the purpose of payment or our operations. We will honor such a request unless law requires us to share that information.
To request restrictions, you must make your request in writing to the Pediatricians of Hyde Park, LLC Compliance Officer. In your
request you may indicate: (1) what information you want to limit; (2) whether you want to limit our practice’s use and/or disclosure;
and (3) to whom you want the limits to apply. For example, you may not want disclosures to be made to your spouse.
Right to Request Confidential Communications: You have the right to request that Pediatricians of Hyde Park, LLC communicate
with you about medical matters in a certain way or at a certain location. To request that our practice communicate in a certain
manner, you must make your request in writing to the Pediatricians of Hyde Park, LLC Compliance Officer. You do not have to state
a reason for your request. Our practice will accommodate all reasonable requests. Your request must specify how or where you
wish to be contacted.
Changes to This Notice
Pediatricians of Hyde Park, LLC reserves the right to change its privacy and security practices and to make the new provisions
effective for all Protected Health Information that our practice holds or maintains. Should our privacy practices change, we will post
the amended Notice of Privacy Practices in our office and on our website.
If you believe your privacy rights have been violated, you may file a complaint with the Pediatricians of Hyde Park, LLC Compliance Officer. To file a complaint with us, you can go to our webpage and do a contact us or you may call the office and ask to speak with our Compliance Officer. You may also file a complaint with the Office for Civil Rights, U.S. Department of Health and Human Services by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/ privacy/hipaa/complaints/.
All complaints should be submitted in writing to:
HIPAA Privacy Officer
3666 Paxton Avenue
Cincinnati, OH 45208
We will NOT retaliate against you in any way for filing a complaint