This notice describes how medical information about your child may be used and disclosed and how you can get access to this information. Please review it carefully.


Your information is important and confidential. Our ethics and policies require that your information be held in strict confidence.
Effective April 14, 2003


At our practice, we are committed to treating and using protected health information (PHI) about our patients responsibly. This Notice of Privacy Practices describes the personal information we collect and how and when we use or disclose that information. It also describes your child’s rights as they relate to his/her protected health information. This Notice is effective April 14, 2003, and applies to all protected health information as defined by federal regulation.

Preserving the Confidentiality of Patient Information

Patient information is deemed confidential by law and is to be protected from inappropriate or unlawful disclosure. Confidential information consists of all information, whether written, maintained electronically, or otherwise known by our practice, that is not by its nature public information. This includes written or medical records as well as knowledge pertaining to a specific medical condition of, or treatment provided to, a patient. Information of this kind comes into the possession or knowledge of our practice employees on a daily

We maintain protocols to ensure the security and confidentiality of our patients’ personal information. We have physical security in our building, passwords to protect databases, and compliance audits. Within our practice, access to your information is limited to those who need it to perform their jobs. If you, the parent or legal guardian, authorize someone other than yourself, (e.g., grandparent, sitter, or friend) to bring your child in for care and treatment, you must give us a written authorization to disclose information to that individual and for them to make treatment decisions.

Uses and Disclosures of Protected Health Information for Treatment, Payment, and Health Operations

1. We will use your child’s health information for treatment. For example: Information obtained by a nurse, physician, or other member of your child’s health care team will be recorded in your record and used to determine the course of treatment that should work best for your child. The information may be used for the coordination or management of your child’s health with a third party. For example, your child’s protected health information may be provided to a physician to whom your child has been referred to ensure that the physician has the necessary information to diagnose or treat him/her.

2. We will use your child’s health information for payment. For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies the patient, as well as his/her diagnosis, procedures, and supplies used.

3. We will use your child’s health information for healthcare operations. For example: We may use or disclose, as-needed, your child’s protected health information in order to support the business activities of the practice.

These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, and licensing. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your updated address and insurance information. We may also call you by name in the waiting room when your physician is ready to see you.

We may use or disclose your child’s protected health information, as necessary, to contact you to remind you of your appointment.

We may disclose patient health information without your authorization for treatment, payment or healthcare operations, or when required by law, for public health activities, for victims of abuse, neglect, or domestic violence, for health oversight, for judicial  proceedings, or for specific law enforcement activities.

Any other uses or disclosures of information will only be made with your signed authorization unless required by law. You may revoke the written authorization as provided by 45 CFR 164.508(b)(5), except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Our Responsibilities

Our practice is required to:

  • Maintain the privacy of your child’s health information,
  • Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about your child,
  • Abide by the terms of this notice,
  • Notify you if we are unable to agree to a requested restriction, and
  • Accommodate reasonable requests you may have to communicate your child’s health information.

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. We will keep a posted copy of the most current notice in our facility containing the effective date. In addition, each time you visit our facility for treatment, you may obtain a copy of the current notice in effect upon request.

Your Rights

You have the right to inspect and copy your child’s protected health information. Under federal law, however, the patient and/or guardian may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your child’s protected health information. This means you may ask us not to use or disclose any part of your child’s protected health information for the purposes of treatment, payment or healthcare operations. You may also request that part of your child’s protected health information not be disclosed to family members or friends who may be involved in your child’s care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If a physician believes it is in your best interest to permit use and disclosure of your child’s protected health information, your child’s protected health information will not be restricted. You then have the right to use another Healthcare Professional.

It is the policy of the practice to contact the parent or guardian by phone or mail with appointment reminders or other communications, such as referrals, school health forms, or billing statements. We will use the phone number(s) and address(es) provided at registration. You have the right to request an alternative contact method.

You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

You have the right to obtain a paper copy of this notice from us, upon request.

For More Information Or To Report A Problem

If you have questions and would like additional information, you may contact our practice’s Privacy Officer at (703) 522-4780.

If you believe your child’s privacy rights have been violated, you can either file a complaint with our Privacy Officer, or with the Office for Civil Rights, U.S. Department of Health and Human Services (OCR). There will be no retaliation for filing a complaint with either our
Privacy Officer or the OCR. The address for the OCR is as follows:

Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201