PURPOSE: This notice describes how medical information about you may be used and disclosed and how you can obtain access to this information. Please read carefully.

The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the services you receive at Pediatric Advanced Therapy. We need this record to provide you with quality care and to comply with certain legal requirements. We are required by law to maintain the privacy of protected health information. This notice will tell you about the ways we may use and share medical information about you.

As a general rule, Pediatric Advanced Therapy will not release any information to outside providers without your written consent. We are a group practice with multiple disciplines. We can consult with our associates when clinically advisable to improve overall patient care.

USE AND DISCLOSURE OF MEDICAL INFORMATION: Following is a list of the different ways we are permitted to use and disclose medical information. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written information you provide may be revoked at any time by writing to us.

• FOR TREATMENT: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students or other people who are taking care of you. We may also share medical information about you to your other health care providers to assist them in treating you. We may discuss medical information about your child with interdisciplinary staff at Pediatric Advanced Therapy to improve their overall care.
• FOR PAYMENT: We may use and disclose your medical information for payment purposes.
• FOR HEALTH CARE OPERATIONS: We may use and disclose your medical information for our health care operations. This might include measuring and improving quality, evaluating the performance of employees, conducting training programs and getting the accreditation, certificates, licenses and credentials we need to serve you.
• ADDITIONAL USES AND DISCLOSURES: In addition to using and disclosing your medical information for treatment, payment, and health care operations, we may use and disclose medical information for the following purposes.
• DECEASED PATIENTS: We may disclose PHI regarding deceased patients as mandated by state of law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person's estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.
• MEDICAL EMERGENCIES: We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.
• FAMILY Involvement in Care: We may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.
• VERBAL PERMISSION: We may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.
• WITH AUTHORIZATION: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.

Court orders and Judicial and Administrative proceedings: We may disclose medical information in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Under limited circumstances, such as court order, warrant, or grand jury subpoena, we may share your medical information with law enforcement officials. We may share limited information with a law enforcement official concerning the medical information of a suspect, fugitive, material witness, crime victim or missing person.

Public Health Activities: As required by law, we may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury or disability, including child abuse or neglect. We may also disclose your medical information to persons subject to jurisdiction of the Food and Drug Administration for purpose of reporting adverse events associated with product defects or problems, to enable product recalls, repairs or replacements, to track products, or to conduct activities required by the Food and Drug Administration. We may also, when we are authorized by law to do so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease

Victims of Abuse, Neglect, or Domestic Violence: We may disclose medical information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or violence or the possible victim of other crimes. We may share your medical information if it is necessary to prevent a serious threat to your health or safety or the health and safety of others. We may also share medical information when necessary to help law enforcement officials capture a person who admitted to being a part of a crime or has escaped from legal custody. If a therapist suspects that child abuse or neglect has occurred, the law requires that it be reported to the proper authorities. Child abuse includes sexual exploitation and physical or mental injuries that result in impaired functioning. Child neglect includes failure to provide for the basic needs of the child (including medical care) and inappropriate discipline.

Health Oversight Committees: We may disclose medical information to an agency providing health over sight for oversight activities authorized by law, including audits, civil, administrative, or criminal investigations or proceedings, inspections, licensure or disciplinary actions, or other authorized activities.

YOUR INDIVIDUAL RIGHTS:

You have a right to:

• Look at or receive copies of your medical information.
• Receive a list of all the times we or our business associates shared your medical information for purposes other than treatment, payment and health care operations and other specified expectations.
• Receive your own confidential health information by alternative means or alternative locations.
• Request that we place additional restrictions on our use or disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the case of an emergency).
• Request that we change your medical information. We may deny your request if we did not create the information you want changed or for certain other reasons. If we deny your request, we will provide you with an explanation. You may respond with a statement of disagreement that will be added to the information you want changed. If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include any changes in any future sharing of that information.
• Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
• Right to Request Confidential Communication. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. We will not ask you for an explanation of why you are making the request.
• Breach Notification. If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself. Right to a Copy of this Notice. You have the right to a copy of this notice.

In each case, you must make your request in writing to the Privacy Officer at Pediatric Advanced Therapy.

QUESTIONS AND COMPLAINTS: If you have any questions about this notice or if you think that we have violated your privacy rights, please contact us. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services. This complaint must be filed within 180 days of when the complainant knew or should have known that the act had occurred. The secretary may waive this 180 day time limit if good cause is shown.

This notice is effective for one year from signature date.
I have read and understand the Privacy Practices of Pediatric Advanced Therapy.

I have received a copy of these privacy practices in my patient portal and understand that I may request a paper copy at any time.