Palm Beach Children's Associates, P.A.

NOTICE OF PRIVACY PRACTICES

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

PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice, please 
contact Lisa Glodis, office manager, of our office at 
(561) 641-6000, 1860 Forest Hill Blvd., #102, West Palm 
Beach, FL 33406.

WHO WILL FOLLOW THIS NOTICE
This notice describes the information privacy practices 
followed by our employees, staff and other office 
personnel. The practices described in this notice will 
also be followed by health care providers you (you and/or 
your child)* consult with by telephone (when your regular 
health care provider from our office is not available) who 
provide "call coverage" for your health care provider.

YOUR HEALTH INFORMATION
This notice applies to the information and records we have 
about your health, health status, and the health care and 
service you receive at this office. We are required by law 
to give you this notice. It will tell you about the ways 
in which we may use and disclose health information about 
you and describes your rights and our obligations 
regarding the use and disclosure of that information.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment We may use health information about you to 
provide you with medical treatment or services. We may 
disclose health information about you to doctors, nurses, 
technicians, office staff or other personnel who are 
involved in taking care of you and your health.

For example, your doctor may be treating you for a heart 
condition and may need to know if you have other health 
problems that could complicate your treatment. The doctor 
may use your medical history to decide what treatment is 
best for you. The doctor may also tell another doctor 
about your condition so that doctor can help determine the 
most appropriate care for you.

Different personnel in our office may share information 
about you and disclose information to people who do not 
work in our office in order to coordinate your care, such 
as phoning in prescriptions to your pharmacy, scheduling 
lab work and ordering x-rays. Family members and other 
health care providers may be part of your medical care 
outside this office and may require information about you 
that we have.

For Payment We may use and disclose health information 
about you so that the treatment and services you receive 
at this office may be billed to and payment may be 
collected from you, an insurance company or a third party. 
For example, we may need to give your health plan 
information about a service you received here so your 
health plan will pay us or reimburse you for the service. 
We may also tell your health plan about a treatment you 
are going to receive to obtain prior approval, or to 
determine whether your plan will cover the treatment.

For Health Care Operations We may use and disclose health 
information about you in order to run the office and make 
sure that you and our other patients receive quality care. 
For example, we may use your health information to 
evaluate the performance of our staff in caring for you. 
We may also use health information about all or many of 
our patients to help us decide what additional services we 
should offer, how we can become more efficient, or whether 
certain new treatments are effective.

Appointment Reminders We may contact you as a reminder 
that you have an appointment for treatment or medical care 
at the office.

Treatment Alternatives We may tell you about or recommend 
possible treatment options or alternatives that may be of 
interest to you.

Health-Related Products and Services We may tell you about 
health-related products or services that may be of 
interest to you.
Please notify us if you do not wish to be contacted for 
appointment reminders, or if you do not wish to receive 
communications about treatment alternatives or health-
related products and services. If you advise us in writing 
(at the address listed at the top of this Notice) that you 
do not wish to receive such communications, we will not 
use or disclose your information for these purposes.

You may revoke your Consent at any time by giving us 
written notice. Your revocation will be effective when we 
receive it, but it will not apply to any uses and 
disclosures that occurred before that time.

If you do revoke your Consent, we will not be permitted to 
use or disclose information for purposes of treatment, 
payment or health care operations, and we may therefore 
choose to discontinue providing you with health care 
treatment and services.

SPECIAL SITUATIONS
We may use or disclose health information about you 
without your permission for the following purposes, 
subject to all applicable legal requirements and 
limitations:

To Avert a Serious Threat to Health or Safety We may use 
and disclose health information about you when necessary 
to prevent a serious threat to your health and safety or 
the health and safety of the public or another person.

Required By Law We will disclose health information about 
you when required to do so by federal, state or local law.

Research We may use and disclose health information about 
you for research projects that are subject to a special 
approval process. We will ask you for your permission if 
the researcher will have access to your name, address or 
other information that reveals who you are, or will be 
involved in your care at the office.

Organ and Tissue Donation If you are an organ donor, we 
may release health information to organizations that 
handle organ procurement or organ, eye or tissue 
transplantation or to an organ donation bank, as necessary 
to facilitate such donation and transplantation.

Military, Veterans, National Security and Intelligence If 
you are or were a member of the armed forces, or part of 
the national security or intelligence communities, we may 
be required by military command or other government 
authorities to release health information about you. We 
may also release information about foreign military 
personnel to the appropriate foreign military authority.

Workers' Compensation we may release health information 
about you for workers' compensation or similar programs. 
These programs provide benefits for work?related injuries 
or illness.

Public Health Risks We may disclose health information 
about you for public health reasons in order to prevent or 
control disease, injury or disability; or report births, 
deaths, suspected abuse or neglect, non?accidental 
physical injuries, reactions to medications or problems 
with products.

Health Oversight Activities We may disclose health 
information to a health oversight agency for audits, 
investigations, inspections, or licensing purposes. These 
disclosures may be necessary for certain state and federal 
agencies to monitor the health care system, government 
programs, and compliance with civil rights laws.

Lawsuits and Disputes If you are involved in a lawsuit or 
a dispute, we may disclose health information about you in 
response to a court or administrative order. Subject to 
all applicable legal requirements, we may also disclose 
health information about you in response to a subpoena.



Law Enforcement We may release health information if asked 
to do so by a law enforcement official in response to a 
court order, subpoena, warrant, summons or similar 
process, subject to all applicable legal requirements.

Coroners, Medical Examiners and Funeral Directors We may 
release health information to a coroner or medical 
examiner. This may be necessary, for example, to identify 
a deceased person or determine the cause of death.

Information Not Personally Identifiable We may use or 
disclose health information about you in a way that does 
not personally identify you or reveal who you are.

Family and Friends We may disclose health information 
about you to your family members or friends if we obtain 
your verbal agreement to do so or if we give you an 
opportunity to object to such a disclosure and you do not 
raise an objection. We may also disclose health 
information to your family or friends if we can infer from 
the circumstances, based on our professional judgment that 
you would not object. For example, we may assume you agree 
to our disclosure of your personal health information to 
your spouse when you bring your spouse with you into the 
exam room during treatment or while treatment is discussed.

In situations where you are not capable of giving consent 
(because you are not present or due to your incapacity or 
medical emergency), we may, using our professional 
judgment, determine that a disclosure to your family 
member or friend is in your best interest. In that 
situation, we will disclose only health information 
relevant to the person's involvement in your care. For 
example, we may inform the person who accompanied you to 
the emergency room that you suffered a heart attack and 
provide updates on your progress and prognosis. We may 
also use our professional judgment and experience to make 
reasonable inferences that it is in your best interest to 
allow another person to act on your behalf to pick up, for 
example, filled prescriptions, medical supplies, or X?rays.

OTHER USES AND DISCLOSURES OF HEALTH INFORMATION
We will not use or disclose your health information for 
any purpose other than those identified in the previous 
sections without your specific, written Authorization. We 
must obtain your Authorization separate from any Consent 
we may have obtained from you. If you give us 
Authorization to use or disclose health information about 
you, you may revoke that Authorization, in writing, at any 
time. If you revoke your Authorization, we will no longer 
use or disclose information about you for the reasons 
covered by your written Authorization, but we cannot take 
back any uses or disclosures already made with your 
permission.

If we have HIV or substance abuse information about you, 
we cannot release that information without a special 
signed, written authorization (different than the 
Authorization and Consent mentioned above) from you. In 
order to disclose these types of records for purposes of 
treatment, payment or health care operations, we will have 
to have both your signed Consent and a special written 
Authorization that complies with the law governing HIV or 
substance abuse records.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information 
we maintain about you:

Right to Inspect and Copy You have the right to inspect 
and copy your health information, such as medical and 
billing records, that we use to make decisions about your 
care. You must submit a written request to our office 
manager in order to inspect and/or copy your health 
information. If you request a copy of the information, we 
may charge a fee for the costs of copying, mailing or 
other associated supplies. We may deny your request to 
inspect and/or copy in certain limited circumstances. If 
you are denied access to your health information, you may 
ask that the denial be reviewed. If such a review is 
required by law, we will select a licensed health care 
professional to review your request and our denial. The 
person conducting the review will not be the person who 
denied your request, and we will comply with the outcome 
of the review.

Right to Amend If you believe health information we have 
about you is incorrect or incomplete; you may ask us to 
amend the information. You have the right to request an 
amendment as long as this office keeps the information.

To request an amendment, complete and submit a Medical 
Record Amendment/Correction Form to our office manager. We 
may deny your request for an amendment if it is not in 
writing or does not include a reason to support the 
request. In addition, we may deny your request if you ask 
us to amend information that:

a) We did not create, unless the person or entity that 
created the information is no longer available to make the 
amendment.
b) Is not part of the health information that we keep.
c) You would not be permitted to inspect and copy.
d) Is accurate and complete.

Right to an Accounting of Disclosures You have the right 
to request an "accounting of disclosures." This is a list 
of the disclosures we made of medical information about 
you for purposes other than treatment, payment and health 
care operations. To obtain this list, you must submit your 
request in writing to our office manager. It must state a 
time period, which may not be longer than six years and 
may not include dates before April 14, 2003. Your request 
should indicate in what form you want the list (for 
example, on paper, electronically). We may charge you for 
the costs of providing the list. We 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 health 
information we use or disclose about you for treatment, 
payment or health care operations. You also have the right 
to request a limit on the health information we disclose 
about you to someone who is involved in your care or the 
payment for it, like a family member or friend. For 
example, you could ask that we not use or disclose 
information about a surgery you had.

We are Not Required to Agree to Your Request If we do 
agree; we will comply with your request unless the 
information is needed to provide you emergency treatment. 
To request restrictions, you may complete and submit the 
Request For Restriction On Use/Disclosure Of Medical 
Information to our office manager.

Right to Request Confidential Communications You have the 
right to request that we communicate with you about 
medical matters in a certain way or at a certain location. 
For example, you can ask that we only contact you at work 
or by mail.

To request confidential communications, you may complete 
and submit the Request For Restriction On Use/Disclosure 
Of Medical Information And/Or Confidential Communication 
to our office manager.  We will not ask you the reason for 
your request. We will accommodate all reasonable requests. 
Your request must specify how or where you wish to be 
contacted.

Right to a Paper Copy of This Notice You have the right to 
a paper copy of this notice. You may ask us to give you a 
copy of this notice at any time. Even if you have agreed 
to receive it electronically, you are still entitled to a 
paper copy. To obtain such a copy, contact our office 
manager.

CHANGES TO THIS NOTICE
We reserve the right to change this notice, and to make 
the revised or changed notice effective for medical 
information we already have about you as well as any 
information we receive in the future. We will post a 
summary of the current notice in the office with its 
effective date in the top right hand corner. You are 
entitled to a copy of the notice currently in effect.

COMPLAINTS
If you believe your privacy rights have been violated, you 
may file a complaint with our office or with the Secretary 
of the Department of Health and Human Services. To file a 
complaint with our office, contact Lisa Glodis, office 
manager, (561) 641-6000 .You will not be penalized for 
filing a complaint.

*You refers to you as the parent and/or your child 
throughout this document