This notice describes how medical information about your child may be used and disclosed, and how you can get access to this information. Please review it carefully.

USES AND DISCLOSURES: We will use your child’s protected health information (PHI) for the purposes of treatment, payment and health care operations.

Treatment includes the disclosure of health information to other providers who have referred your child for services or are involved in his/her care. This may include doctors, nurses, other occupational therapists, physical therapists or speech therapists, psychologists, regional center service coordinators or schools.

Payment includes the disclosure of health information to your insurance company or to a school district or regional center so payment can be obtained for services rendered.

Health Care Operations includes the utilization of your child’s records to monitor the quality of care being given at our facility.

Other Special Uses: Our practice may use your child’s PHI to request information about your child or to send you information regarding other health or therapy-related services.

Uses and Disclosures Required by Law: The federal health information privacy regulations either permit or require us to use or disclose your child’s PHI in the following ways: we may share some of your child’s PHI with a family member or friend involved in your child’s care if you do not object, or we may use your child’s PHI in an emergency situation when you may not be able to express your wishes for your child. We may also disclose your child’s PHI when we are required to do so by law, for example, by court order or subpoena. Disclosures to health oversight agencies are sometimes required by law to report certain diseases or adverse drug reactions. We may use and disclose health information about your child to avert a serious threat to your child’s health or safety, or to the health or safety of the public or others. Your authorization is required before your child’s PHI may be used or disclosed by us for any other purposes.

Restrictions: You have the right to request restrictions on how your child’s PHI is used, however, we are not required to agree with your request. If we do agree, we must abide by your request.

Confidential Communications: You have the right to request in writing the way we communicate with you about medical matters in a certain way or at a certain location.

Access to PHI: You have the right to request a copy of your child’s medical record. This request must be in writing and we may charge a fee to cover the costs of copying and mailing.

Amendments: If you feel that medical information we have about you or your child is incomplete or inaccurate, you may request an amendment in writing. Your request may be denied if you do not include a reason to support the request.

Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about your child for treatment, payment, or health care operations.

Accounting of Disclosures: You have the right to request in writing, a list accounting for any disclosures of your child’s medical information we have made, except for uses and disclosures for treatment, payment, and health care operations, as previously described.

Paper Copy: You have the right to have a paper copy of this notice at any time.

COMPLAINTS: If you feel that your privacy rights have been violated, you have the right to make a complaint to us in writing without fear of retaliation. Your complaint should contain enough specific information so that we may adequately investigate and respond to your concerns. If you are not satisfied with our response, you may complain directly to the Secretary of Health and Human Services.

OTHER USES OF MEDICAL INFORMATION: Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permissions.

I have reviewed the above Notice of Privacy Practices.

Please sign below.