Pediatric Speech & Language Services, Inc.

NOTICE OF PRIVACY PRACTICES

1. Pediatric Speech & Language Services, Inc. may use and disclose protected health information for treatment, payment and healthcare operations. Examples of these include, but are not limited to, requested preschool, or sports physicals, foster care homes, home health agencies and/or referral to other providers for treatment, notify you of appointments by phone, email, text, or U.S. mail. Payment examples include, but are not limited to, insurance companies for claims including coordination of benefits with other insurers; collection agencies. Healthcare operations include, but are not limited to, internal quality control and assurance including auditing of records.
2. Pediatric Speech & Language Services, Inc. is permitted or required to use or disclose protected health information without the individual’s written consent or authorization in certain circumstances. Two examples of such are for public health requirements or court orders.
3. Pediatric Speech & Language Services, Inc. will not use or disclose PHI for marketing purposes and/or disclosures constituting a sale of PHI without the
   individual’s Authorization.
4. Pediatric Speech & Language Services, Inc. will not sell or make any other use or disclosure of a patient’s protected health information without the individual’s written authorization. Such authorization may be revoked at any time. Revocation must be written.
5. Pediatric Speech & Language Services, Inc. will abide by the terms of this notice currently in effect at the time of the disclosure.
6. Pediatric Speech & Language Services, Inc. reserves the right to change the terms of its notice and to make new notice provisions effective for all protected health information that it maintains. Pediatric Speech & Language Services, Inc. will provide each patient with a copy of any revisions of its Notice of Information Practices at the time of their next visit, or at their last known address if there is a need to use or disclose any protected health information of the patient. Copies may also be obtained at any time at our offices.
7. Any patient, guardian or personal representative has the right to object to the use of their health information for directory purposes.
8. Any patient, guardian or personal representative has the right to inspect and obtain copies of their medical record. The records will be provided within 30 days of the request, and a reasonable charge may be assessed for any copies after the first request in a 12-month period. If Pediatric Speech & Language Services, Inc. is unable to act within the required period, Pediatric Speech & Language Services, Inc. , may provide the patient with written notice of the reason for delay and expected date of completion of the request. This extension of time will not exceed 30 days.
9. Any patient, guardian or personal representative has the right to request amendments be made to their medical record.
10. Any patient, guardian or personal representative has the right to request a 6-year accounting of all disclosures of their medical record. The history will be provided within 30 days of the request and a reasonable charge may be assessed for any copies after the first requested in a 12-month period. If Pediatric Speech & Language Services, Inc. is unable to act within the required period, Pediatric Speech & Language Services, Inc. may provide the patient/person with written notice of the reason for delay and expected date of completion of the request. This extension of time will not exceed 30 days.
11. Any patient, guardian or personal representative has the right to request restrictions as to how their health information may be used or disclosed to carry out treatment, payment or healthcare operations. Pediatric Speech & Language Services, Inc. is not required to agree to the restrictions requested, but if Pediatric Speech & Language Services, Inc. does agree, Pediatric Speech & Language Services, Inc. must abide by those restrictions.
12. Any patient, guardian or personal representative has the right to restrict disclosure of certain Personal Health Information to a health plan for payment or health care operation purposes, but not for treatment purposes, for items or services that have been paid in full and out-of-pocket.
13. Any person/patient has the right to be notified by the Pediatric Speech & Language Services, Inc. Security Officer following a breach of unsecured Personal Health Information of the affected individual. Pediatric Speech & Language Services, Inc. may use email to notify the person/patient of a breach.
14. Any person/patient may file a complaint to Pediatric Speech & Language Services, Inc. and to the U.S. Secretary of Health and Human Services if they believe their privacy rights have been violated. To file a complaint with the Practice, please contact the Privacy Officer at the following address and/or phone number P.O. Box 9804, Greensboro, NC 27429; telephone (336) 541-8167. All complaints will be addressed and the results will be reported to the Privacy Officer.
15. It is the policy of Pediatric Speech & Language Services, Inc. that no retaliatory action will be made against any individual who submits or conveys a complaint of suspected or actual non-compliance of the privacy standards.

Download and sign the form and return to your Therapist.