Patient Privacy
Notice of Privacy Practices
Harpeth Pediatrics
effective date: September 23, 2013

This notice describes how your child’s medical information may be used and disclosed and how you can get access to this information. Please review it carefully. It explains how the physicians and staff of Harpeth Pediatrics may use and disclose your protected health information (PHI) for purposes of treatment, payment, and health care operations, and for other purposes that are permitted or required by law.

If you have any questions about this notice, or if you need more information, please contact our Privacy Officer:

Privacy Officer: Libby Robbins
Mailing Address: 4085 Mallory Lane, Suite 204, Franklin, TN 37067
Telephone: 615-771-2656
Fax: 615-771-2659

Our Responsibilities:
Harpeth Pediatrics takes the privacy of your/your child’s health information seriously. We are required by law to maintain the privacy of your health information and provide you with this Notice of Privacy Practices. We will abide by terms of this Notice of Privacy Practices. We reserve the right to change this Notice of Privacy Practices and to make any new Notice of Privacy Practices effective for all protected health information that we maintain. Any new Notice of Privacy Practices adopted will be posted in our lobby and on our website ( and made available at your next appointment.

What is Protected Health Information (PHI)?
Protected health information (PHI) is demographic and individually identifiable health information that will or may identify the patient and relates to the patient’s past, present or future physical or mental health or condition and related health care services.

How We May Use and Disclose your PHI:

For Treatment. We may use PHI to give you medical treatment or services and to manage and coordinate your medical care. For example, we may disclose PHI to doctors, nurses, technicians, or other personnel who are involved in taking care of you, including people outside our practice, such as referring or specialist physicians, labs, pharmacies, and hospitals.

For Payment. We may use and disclose PHI so that we can bill for the treatment and services you get from us and can collect payment from you, an insurance company, or another third party. For example, we may need to give your health plan information about your treatment in order for your health plan to pay for that treatment. We also may tell your health plan about a treatment you are going to receive to find out if your plan will cover the treatment.

For Health Care Operations. We may use and disclose PHI for our health care operations, such as conducting quality assessment and improvement activities, contracting with insurance companies, conducting medical review and auditing services, and general administrative and business functions.

Appointment Reminders. We may use and disclose PHI to contact you to remind you that you have an appointment for medical care.

Minors. We may disclose the PHI of minor children to their parents or guardians unless such disclosure is otherwise prohibited by law.

As Required by Law. We will disclose PHI about you when required to do so by international, federal, state, or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose PHI when necessary to prevent a serious threat to your health or safety or to the health or safety of others.

Business Associates. We may disclose PHI to our business associates who perform functions on our behalf or provide us with services if the PHI is necessary for those functions or services. All of our business associates are obligated, under contract with us, to protect the privacy of your PHI.

Health Oversight Activities. We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, licensure, and similar activities that are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Uses and Disclosures that Require Us to Give You an Opportunity to Opt Out

Individuals Involved in Your Care or Payment for Your Care. We may disclose PHI to a person who is involved in your medical care or helps pay for your care, such as a family member or friend, to the extent it is relevant to that person’s involvement in your care or payment related to your care. We will provide you with an opportunity to object to and opt out of such a disclosure whenever we practicably can do so.

Disaster Relief. We may disclose your PHI to disaster relief organizations that seek your PHI to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we can practicably do so.

Your Written Authorization is Required for Other Uses and Disclosures
When you, as the patient or the parent or guardian of a patient, sign a consent form, you are giving Harpeth Pediatrics permission to use and disclose protected health information for the purposes of treatment, payment and health care operations. You will need to sign a separate authorization to have protected health information released for any reason other than treatment, payment or health care operations. You may change your mind and revoke an authorization, except (1) to the extent that we have relied on the authorization up to that point, (2) if the authorization was obtained as a condition of obtaining insurance coverage. All requests to revoke an authorization should be in writing.

When is my Authorization/Consent Not Required?
The law requires that some information may be disclosed without your authorization in the following circumstances:
-In case of an emergency
-When there are communication or language barriers
-When required by law
-When there are risks to public health
-To conduct health oversight activities
-To report suspected child abuse or neglect
-To specified government regulatory agencies
-In connection with judicial or administrative proceedings
-For law enforcement purposes
-To coroners, funeral directors, and for organ donation
-In the event of a serious threat to health or safety

Your Rights Regarding Your PHI

Right to Inspect and Copy. You have the right to inspect and/or receive a copy of PHI that may be used to make decisions about your care or payment for your care. We may charge you a fee for the costs of copying, mailing or other supplies associated with your request.

Right to an Electronic Copy. You have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We may charge you a reasonable cost-based fee for the labor associated with providing you this service. If you choose to have your PHI transmitted electronically, you will need to provide a written request to this office listing the contact information of the individual or entity who should receive your electronic PHI.

Right to Receive Notice of a Breach. We are required to notify you by first class mail or by email (if you have indicated a preference to receive information by email) of any breach of your unsecured PHI.

Right to Request Amendments. If you feel that PHI we have is incorrect or incomplete, you may ask us to amend the information. A request for amendment must be made in writing. We may deny your request if it is not in writing or if (1) the information was not created by us, (2) is not part of the medical information kept by us, (3) is not information that you would be permitted to inspect and copy, or (4) is accurate and complete. If we deny your request, you may submit a written statement of disagreement of reasonable length. Your statement of disagreement will be included in your medical record, but we may also include a rebuttal statement.

Right to an Accounting of Disclosures. You have the right to ask for an accounting of disclosures, which is a list of the disclosures we made of your PHI. We are not required to list certain disclosures, including (1) disclosures made for treatment, payment and healthcare operations purposes, (2) disclosures made with your authorization, and (3) disclosures made directly to you. You must submit your request in writing, and your request must state a time period but may not be longer than 6 years before your request.

Right to Request Restrictions. You have the right to request a restriction or limitation on the PHI we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your child’s care or the payment of your child’s care. We are not required to agree with your request.

Right to Restrict Certain Disclosures to Your Health Plan. You have the right to restrict certain disclosures of PHI to a health plan if the disclosure is for payment or health care operations and pertains to a health care item or service for which you have paid out of pocket in full. We will honor this request unless we are otherwise required by law to disclose this information. This request must be made at the time of service.

Right to Request Confidential Communications. You have the right to request that we communicate with you only in certain ways to preserve your privacy. For example, you may request that we contact you by mail at a special address or call you only at your work number. You must make any such request in writing and you must specify how or where we are to contact you. We will accommodate reasonable requests. We will not ask you for the reason for your request.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time. You can get a copy of this Notice at our website:

How to Exercise your Rights
To exercise your rights described in this Notice, send your request, in writing, to our Pricacy Officer at the address listed at the beginning of this Notice. We may ask you to fill out a form that we will supply. To get a paper copy of this Notice, contact our Privacy Officer by phone or mail.

Changes to This Notice
The effective date of the Notice is stated at the beginning. We reserve the right to change this Notice. We reserve the right to make the changed Notice effective for PHI we already have as well as for any PHI we create or receive in the future. A copy of our current Notice is posted in our office and on our website.

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact our Privacy Officer at the address listed at the beginning of this Notice. All complaints must be made in writing and should be submitted within 180 days of when you knew or should have known of the suspected violation. There will be no retaliation against you for filing a complaint.