SURFSIDE PEDIATRICS, INC.
2660 E. MAIN STREET, SUITE 204
VENTURA, CA 93003
(805)643-7510 FAX NOTICE OF PRIVACY PRACTICES AND FINANCIAL RESPONSIBILITY 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. Surfside Pediatrics is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.
Disclosure of Your Health Care Information
Treatment We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations. (example) “On occasion, it may be necessary to seek consultation regarding your condition from other health care providers associated with Surfside Pediatrics.” “It is our policy to provide a substitute health care provider, authorized by Dr. Kevin White to provide assessment and/or treatment to our patients, without advanced notice, in the event of your primary health care provider’s absence due to vacation, sickness, or other emergency situation.”
Payment We may disclose your health information to your insurance provider for the purpose of payment or health care operations. (Example) “As a courtesy to our patients, we will submit an itemized billing statement to your insurance carrier for the purpose of payment to Surfside Pediatrics for health care services rendered. If you pay for your health care services personally, we will, as a courtesy, provide an itemized billing to your insurance carrier for the purpose of reimbursement to you. The billing statement contains medical information, including diagnosis, date of injury or condition, and codes which describe the health care services received.”
Workers’ Compensation We may disclose your health information as necessary to comply with State Workers’ Compensation Laws.
Emergencies We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death.
Public Health As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure.
Judicial and Administrative Proceedings. We may disclose your health information in the course of any administrative or judicial proceeding.
Law Enforcement. We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes.
Deceased Persons. We may disclose your health information to coroners or medical examiners.
Research. We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board.
Public Safety. It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.
Specialized Government Agencies. We may disclose your health information for military, national security, prisoner and government benefits purposes.
Marketing. We may contact you for marketing purposes, as described below: (example)
“As a courtesy to our patients, it is our policy to call your home on the evening prior to your scheduled appointment to remind you of your appointment time. If you are not at home, we leave a reminder message on your answering machine or with the person answering the phone. No personal health information will be disclosed during this recording or message other than the date and time of your scheduled appointment along with a request to call our office if you need to cancel or reschedule your appointment.”
Linking. Our website may offer links to other websites. Please be aware that we are not responsible for the Privacy Practices of such linked websites, including websites of our partners. We encourage our users to be aware when they leave our website to read the privacy statements of each and every website that collects personally identifiable information. This privacy statement applies solely to information collected by our website.
Your Health Information Rights You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that Surfside Pediatrics is not required to agree to the restriction that you requested. You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request. You have the right to inspect and copy your health information. You have a right to request that Surfside Pediatrics amend your protected health information. Please be advised, however, that Surfside Pediatrics is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s)and information about how you can disagree with the denial. You have a right to receive an accounting of disclosures of your protected health information made by Surfside Pediatrics. You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.
Changes to this Notice of Privacy Practices Surfside Pediatrics reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, Surfside Pediatrics is required by law to comply with this Notice. Surfside Pediatrics is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information.
Complaints Complaints about your Privacy rights or how Surfside Pediatrics has handled your health information should be directed to Valerie White by calling this office at 805-643-7500. If Valerie White is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days. If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to: DHHS, Office of Civil Rights
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201
Proof of insurance and payment is due at the time of visit. I authorize Surfside Pedaitrics to bill my child's insurance for services rendered. Any amount not covered by my child's primary insurance will be my responsiblity. We do not accept MediCal insurance and will not accept it as an alternative to your current insurance plan.