Privacy Statement

Effective Date of this Notice January 1, 2003
Pediatric & Adolescent Health Partners, P.C.

Notice of Privacy Practices As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act (HIPAA)


Our practice is dedicated and committed to maintaining the privacy of your individually identifiable health information (IIHI). In conducting our business, we will create records regarding you and your child and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you and your child. We are also 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 this notice of privacy practices.

We realize that the laws are complicated, but we mustprovide 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, and you may request a copy of our most current Notice at any time.



1. Treatment: Our practice may use your childs IIHI to treat your child. For example, we may ask that laboratory tests be performed on your child and we may use the results to help us reach a diagnosis. We may use your childs IIHI in order to write a prescription for your child, or we might disclose your childs IIHI to a pharmacy when we order a prescription for your child. We may release IIHI to another health care provider to whom we refer your child for future care.

2. Payment: Our practice may use and disclose your IIHI in order to bill for the services and items you may receive from us. For example, we may contact your health insurer to certify that your child is eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your childs treatment to determine if your insurer will pay for your childs treatment.

3. Health Care Operations: Our practice may use and disclose your IIHI to operate our business. For example our practice may use your childs IIHI to evaluate the quality of care your child 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 to assist in their health care operations.

4. Appointment Reminders: Our practice may use and disclose your childs 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 and alternatives, and services that may be of interest to you.

6. Release of Information to Family/Friends: Our practice may release your childs IIHI to a friend or family member who is involved in your childs care, with your written permission. For example, a parent or guardian may ask that a babysitter take their child to the pediatrician for treatment of a cold. In this example, the babysitter may have access to this childs medical information regarding this visit.

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

B: USE AND DISCLOSURE OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI)IN SPECIAL CIRCUMSTANCES The following categories describe unique scenarios in which we may use or disclose identifiable health information.

1. Public Health Risks: Pediatric & Adolescent Health Partners may disclose your childs IIHI to public health authorities that are authorized to collect information for the purpose of: maintaining vital records, such as birth and death; reporting child abuse or neglect; preventing or controlling disease, injury or disability; notifying a person regarding potential risk to a communicable disease; notifying a person regarding a potential risk for spreading or contracting a condition; reporting reactions to drugs or problems with products or devices.

2. Health Oversight Activities: Our practice may disclose 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.

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

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

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 may also release information for funeral directors to perform their job.

6. Serious Threats to Health or Safety: Our practice may use and disclose your childs IIHI when necessary to reduce or prevent a serious threat to health and safety to you, your child or another individual or the public.

7. National Security: Our practice may disclose IIHI to federal officials for intelligence and national security activities authorized by law, to protect the President, other officials, or to conduct investigations.

8. Inmates: Our practice may disclose IIHI to correctional institutions or law enforcement officials if the the patient is an inmate or under custody of a law enforcement official. Disclosure for these purposes would be necessary for the institution to provide health care services to the patient, for the safety and security of the institution, and/or to protect the patients health and safety or the health and safety of other individuals.


Parents, Guardians, and Patients Have the Following Rights Regarding Their Individually Identifiable Health Information (IIHI).

1. Confidential Communications: You have the right to request that our Practice communicate with you about your childs’ health and other 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 our Office Manager, at 794-2821, which will be kept in your childs file, 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.

2. Requesting Restrictions: You have a 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 childs care or the payment for 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 childs IIHI, you must make the request in writing to our Office Manager. Your request must describe in clear and concise fashion:

  1. the information you wish restricted;
  2. whether you are requesting to limit our practices’ use, disclosure or both; and
  3. to whom you want the limits to apply.

3. Inspection and Copies: You have the right to inspect and obtain a copy of the IIHI that may be used to make decisions about your child, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to our Office Manager at 13821 A Village Mill Drive, Midlothian, VA 23114. Requests are processed through Smart Corporation and they will 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 the review.

4. Amendment: You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. Your request must be made in writing and submitted to the Privacy Officer at Pediatric & Adolescent Health Partners, PC, 13821 A Village Mill Drive, Midlothian, VA 23114. 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.

5. Right to a Paper Copy of This Notice: You are entitled to receive a paper copy of our notice of privacy practices. To obtain a paper copy, contact the Office Manager at (804)794-2821.

6. 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 our Office Manager at (804)794-2821. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

7. 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.

8. Right to a List of Disclosures. You have the right to request a list of disclosures we have made of IIHI about your child. This list will not include disclosures made for treatment, payment, or health care operations, for the purposes of national security, made to law enforcement or corrections personnel or made pursuant to your authorization or made directly to you. To request this list, you must submit your request in writing to Pediatric & Adolescent Health Partners, 13821 A Village Mill Drive, Midlothian, VA 23114.

If you have questions regarding our health information privacy policy, please contact the Privacy Officer at (804) 794-2821.

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