NOTICE OF PA PRIVACY POLICIES AND PRACTICES

THE PRIVACY OF ALL PA CLIENTS' HEALTH INFORMATION IS IMPORTANT TO US. THIS NOTICE CONVEYS HOW HEALTH INFORMATION ABOUT OUR CLIENTS MAY BE USED OR DISCLOSED AND HOW YOU CAN ACCESS YOUR OR YOUR CHILD'S HEALTH INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY, SIGN, AND RETURN THE ACKNOWLEDGEMENT OF RECEIPT.

LEGAL RESPONSIBILITY
PA is required by federal and state law to maintain the privacy of your or your child's health information. We are also required to inform you about our privacy policies and practices, our legal duties and your rights. We will follow the privacy practices described in this notice while it is in effect.

We reserve the right to change our privacy policies and practices and the terms of this notice at any time, as permitted by federal and state law, when new provisions arise to protect the health information that we maintain. If changes are made, the new notice will be distributed. For further information or to request a copy of this notice, contact our privacy officer.

To maintain privacy of client information, we ask that no one enter private therapy rooms or work areas unless accompanied by clinic personnel, your child's speech-language pathologist or your own clinician.

PATIENT/CLIENT RIGHTS
Access: You have the right to access your own or your child's health information. You may view it on site and/or have PA make photocopies (for a cost). All requests for access must be in writing and an appointment time will be set. In certain circumstances we may deny your request, but we will tell you in writing of our decision and any reason(s) for a denial. Contact our privacy officer for all requests.

Amendment: You have the right to request that we amend your own or your child's health information. All requests to amend information must be in writing and include an explanation of why you want the record amended. We may deny your request if the information:

  • was not created by us (e.g. report from another professional),
  • is not part of the protected health information we keep, or
  • is determined by us to be accurate and complete.

If we deny the requested changes, we will tell you in writing how to submit a statement of disagreement that can become a part of your or your child's record. Contact our privacy officer for change requests.

Restriction: You have the right to request additional restrictions regarding our use or disclosure of your own or your child's health information. All requests for additional restrictions to information must be in writing. We may deny your request under certain circumstances. The law allows information disclosure without your authorization in response to:

  • court order, subpoena, warrant, or similar process,
  • health oversight agencies,
  • report about victims of abuse, neglect, or domestic violence, or
  • public health activities.

Alternative Communication: You have the right to request that we communicate or send information to you at an alternate address or by alternate means (e.g. only by phone or only in person). Requests for alternative communication must be in writing and specify which location or method you prefer.

Disclosure: You have the right to a written accounting of the instances in which Peninsula Associates discloses your or your child's health information for purposes other than treatment, payment or healthcare operations. The list will not include disclosures made for national security purposes or to law enforcement personnel.

USES AND DISCLOSURES OF HEALTH INFORMATION
We may use and disclose health information relative to treatment, payment, and healthcare operations.

Treatment: With your permission, we may use or disclose information to other healthcare providers involved in your or your child's care (e.g., physician, school speech therapist, psychologist). We may also discuss aspects of therapy programs at staff meetings to coordinate therapy between staff members or to discuss methods that other staff suggests to maximize progress.

Office Staff: PA office staff (e.g., office coordinator, bookkeeper) handles client and billing information. All office staff members are required to keep any information about PA clients confidential.

Payment: PA may use or disclose your or your child's health information to assist you to in obtaining third-party reimbursement for speech-language services. This may include but is not limited to: evaluation reports, treatment/chart notes, progress reports, or other documentation required by your health insurance company or flexible medical spending account.

Healthcare Operations: PA may use or disclose your or your child's health information as it relates to our healthcare operations. This may include PA operations such as performance reviews, staff and student training programs, and quality assurance and improvement.

Required by Law: PA may use or disclose health information when we are required to do so by law.

Abuse or Neglect: PA may use or disclose health information to appropriate authorities if we have reason to believe that the client is a possible victim of abuse, neglect, domestic violence, or other crimes. We may use or disclose health information to the extent necessary to prevent a serious threat to the client's safety or health, or to the safety and health of others.

Appointment Reminders: PA may use or disclose health information to provide an appointment reminder by voicemail, email, or letter. If you do not wish to have us leave messages at your work via email, or by any other means, please notify us in writing.

Authorization: In addition to our use and disclosure of health information about you or your child for treatment, payment, and healthcare operations, we may use your information for other purposes with your written authorization, e.g., videotaping for speech-language pathologist training. We do not use a client's health information for marketing purposes or communications without written authorization. You may revoke authorizations at any time.

PA cannot use or disclose health information for any reasons except those described in this notification without your written authorization.

FOR MORE INFORMATION OR TO REPORT A PROBLEM
If you want more information or have questions about our privacy policies and practices, please contact our privacy officer, Lynne Orange.

If you are concerned that your privacy rights may have been violated or if you disagree with a decision we have made regarding access to information or in response to a written request you have made, please contact our privacy officer. You may also submit a written complaint to the U.S. Department of Health and Human Services. Our privacy officer will provide you with the address upon request.

PA supports your right to the privacy of your or your child's health information and will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Heath and Human Services.

Privacy Officer Lynne Orange, HR Director
Peninsula Associates - Speech, Language and Learning Specialists
760 Polhemus Rd., San Mateo, CA 94402
650-349-8717 ext. 23
lorange@paspeech.com

PENINSULA ASSOCIATES
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY POLICIES AND PRACTICES Form