Effective Date of Notice: August 1, 2022
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!
Every time a patient comes in for a visit, Palm Tree Pediatrics, plc, (hereafter, “PTP”) will create a record that describes the treatments and services it provided. In compliance with applicable laws, PTP is committed to maintaining the privacy of your personal health information. Protected personal health information includes facts about your past, present, or future physical or mental health, as well as relevant demographic data. To be sure, PTP has put in place policies and procedures to help protect your personal health information. PTP is required to provide this notice outlining its legal obligations that are related to the disclosure of patient-identifiable health information, privacy practices, and examples of how it may use and/or disclose such information.
PTP will adhere to the terms of this notice, subject to revision at any time. It will post the revised notice in the office in a prominent location. As a patient of PTP, you may also request a copy of the practice’s most current notice at any time. Be advised that all revisions to the notice will become effective for all health care information, past, present, or future that PTP maintains.
Be further advised that PTP may use your individual identifiable health information for the following purposes without your authorization.
Health Care Operations:
PTP may disclose your health information without your authorization when permitted or required to by law, including:
PTP may also disclose your information to family members and/or other persons involved in your care or payment for your care. PTP may leave messages for you at home or work about your visits or test results. IF you do not want it to do so, please inform PTP in writing.
All other uses and disclosures of your information to others will require a written, signed authorization from you. You have the right to revoke your authorization at any time except to the extent that we have already acted on it. Should you require your records to be released, PTP will provide you with an authorization form to complete and return to the address listed on it.
YOUR HEALTH RECORD IS THE PHYSICAL PROPERTY OF PALM TREE PEDIATRICS. THE INFORMATION CONTAINED IN IT BELONGS TO YOU. FOLLOWING IS A LIST OF YOUR RIGHTS REGARDING INDIVIDUALLY IDENTIFIABLE PERSONAL HEALTH INFORMATION. ALL REQUESTS RELATED TO THESE ITEMS MUST BE MADE IN WRITING TO PALM TREE PEDIATRICS (ITS PRIVACY OFFICER) AT THE ADDRESS LISTED BELOW. PTP WILL PROVIDE YOU WITH APPROPRIATE FORMS TO EXERCISE THESE RIGHTS. IT WILL NOTIFY YOU IN WRITING IF YOUR REQUESTS CAN NOT BE GRANTED.
Restriction on Use and Disclosure: you have the right to request restrictions on how PTP uses and discloses your health information. This includes requests to restrict disclosure of your health information to only certain individuals, or entities, involved in your care such as family members and insurance companies. PTP is not required to agree with your request. If it agrees, it is bound by the agreement unless disclosure is otherwise required or authorized by law.
Accounting of Disclosures:
Copy of Notice:
If you have questions about this notice, please contact PTP at 14741 W. Mountain View Blvd. Unit #149, Surprise, Arizona 85374 or at (623) 975-5400.