Privacy Practice

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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.

Treatment: 

• PTP may use and disclose your identifiable health information to treat you and assist others in your treatment. For instance, it may send a copy of your records to another physician so that you can be evaluated for specific condition, or it may disclose information to others who take part in your care, such as your spouse, children, or parents. 
   

Payment: 

• PTP may use your health information to bill and collect payment for services provided. This may include providing your insurance company with details of your treatment, sharing your payment information with other treatment providers, contacting you over the phone or through the mail about balances, or sending unpaid balances to a collection agency. 
   

Health Care Operations: 

• PTP may use and disclose health information to operate our business. For example, your health information may be sued to evaluate the quality of care it provides, for state licensing, or to identify you by name when you visit the office.
   

Appointment Reminders:

• PTP may use and disclose your information to remind you of appointments. It may also mail you a reminder for follow-up visits. 
   

Treatment Options: 

• PTP may use your health information to inform you of treatment options or other health-related services it offers that may be of interest to you.
   

Business Associates:

• PTP may share your health information with other individuals or companies that perform various activities for, or on behalf of, our office such as after-hours telephone answering, billing, or quality assurance. Its Business Associates agree to protect the privacy of your information. 
   

PTP may disclose your health information without your authorization when permitted or required to by law, including:

• For public health activities including reporting certain communicable diseases.
• For workers’ compensation or similar programs as required by law.
• To authorities when we suspect abuse, neglect, or domestic violence.
• To health oversight agencies.
• For certain judicial and administrative proceedings pursuant to an administrative order.
• To medical examiner, coroner, or funeral director. 
• For the facilitation of organ, eye, or tissue donation if you are an organ donor. 
• For research purposes under strictly limited circumstances. 
• To avert a serious threat to your health and safety or that of others.
• For governmental purposes such as military service or for national security. 
• In the event of an emergency or for disaster relief.
• In any other instance required by law. 

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.

Confidential Communications: 

• You have the right to request that it communicates with you in a particular manner or at a certain location. For example, you may request that it contacts you only at home. We will accommodate reasonable requests. 

Access: 

• You have the right to inspect or request a copy of records used to make decisions about your health care, including your medical chart and billing records. This office will schedule appointments for record inspection. It may charge a fee for providing you copies of your records. Under special circumstances, it may deny your request to inspect and/or copy your records You may request a review of this denial. 

Record Amendment:

• You have the right to request amendments to your health records created by and for PTP if you feel they are incorrect or incomplete. It may accept or deny your request. If it denies your request, you have the right to provide a statement of disagreement.

Accounting of Disclosures:

• You have the right to receive an accounting of disclosures. This means you may request a list of certain disclosures PTP has made of your records. Upon your request, it will provide this information to you one time free during each twelve (12)-month period. There may be a fee for additional copies.

Copy of Notice:

• You have the right to request that PTP provides you with a paper copy of this notice of Privacy Practices

Written Complaint:

• You have the right to file a written complaint with PTP, if you feel your privacy rights have been violated. You may also file a complaint with the Secretary of the Department of Health and Human Services. There will be no retaliation for filing a complaint.

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.