Monroe Pediatric Associates
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Pediatricians of New York Monroe Pediatric Associates

Monroe Pediatrics is a division of Allied Pediatrics of New York

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Monroe Pediatric Associates, P.C. Notice of Privacy Practices


Effective April 14, 2003



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



Dear Valued Patient:


The federal government has enacted sweeping new regulations that concern the security and privacy of all healthcare information.  The following is a brief description of your rights to security and privacy of your/your child’s medical records.


Release of Your Protected Health Information


One key concept that we must explain is “individually identifiable healthcare information,” which, for our purposes, is called “Protected Health Information” (“PHI”).  This is information about your/your child’s medical care (including what the treatment was for and what the medical condition is) which can be linked to a patient as an individual because it contains such information as the patient’s name, social security number, address or telephone number.  Under these regulations, we are required to maintain the privacy of your PHI and provide you with this notice.


The following are examples of ways we may use or disclose PHI or may be required to use or disclose PHI.  We may use you/your child’s PHI for the purposes of treatment, payment and operations within our practice.  This includes such things as writing prescriptions, billing forms directly to insurers, and collection activities.  We may also contact you to remind you of your/your child’s appointment or with alternate treatment options.  Unless you instruct us otherwise, we may leave a message for you on any answering device or with any person who answers the phone at your residence. PHI may be released where law (including reports of child abuse), for public health activities, for limited law enforcement activities, responding to legal proceedings, for serious threats to patient health or safety, to the military (if member), for inmates, for workers’ compensation, for national defense and security reasons, to Health Oversight Agencies, and to the FDA.  We may also disclose PHI to anyone you have authorized to seek treatment for your child.  In some cases, we may be required to inform you of a request for such disclosures.


We cannot release other medical records or PHI for any other purposes without your written authorization.  For example, we cannot provide your/your children’s school with any PHI without your written permission to do so.  Once you have given authorization for us to disclose PHI, you have the right to, in writing, revoke the authorization for future disclosures.


In all cases, except active medical treatment, we will try to limit any release of your/your child’s PHI to the minimum amount possible.


Please consider that any information so released is no longer protected by the privacy regulations and is subject to further release by the party to whom it has been released.



Rights Regarding Protected Health Information


A. You have the right to see, copy and review any of your/your child’s medical records (except as limited by applicable New York and Federal Law).  A minimal fee for copying records may be charged.


B. You have the right to request us to amend/correct your/your child’s medical records. We are not required to agree with all requests.


C. You have the right to request limits to the disclosure of your/your child’s PHI for treatment, billing and operations purposes.  We are not required to agree to all requests.


D. You may request reasonable confidential communications, such as asking to be called at home rather than work.


E. You have the right to request an accounting of disclosures of PHI for you/your child.  For repeated request, a minimal fee may be charged.  This accounting can be for up to a six (6) year period, but not prior to April 14, 2003.


F. You have the right to request a copy of this notice.


G. You have the right to make a complaint if you feel the privacy or security of you/your child’s PHI has been violated. These complaints will be kept confidential.  You will not be retaliated against for filing a complaint.



For any requests for exercising the above rights, please ask our staff for an applicable form or submit in writing to the Privacy Officer. Complaints can also be directed to the Dept. of Health and Human Services.


Monroe Pediatrics reserves the right to change its privacy policies with notice to patients of any material changes.


Thank you for reading and carefully considering the information presented in this document. If you have any questions regarding this Notice or our Privacy Practices, you may contact our Privacy Officer at 782-7127.