RDV Sportsplex Pediatrics (aka Pro Star Pediatrics, PA) Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our Notice before signing this form. As provided in our Notice, the terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office or by visiting our website at www.rdvpediatrics.com.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement.

During your care at RDV Sportsplex Pediatrics, it may be medically necessary to obtain a blood, urine, stool, tissue, or other type of biological specimen for analysis (ex: a throat swab to test for strep). This analysis will not involve the examination of your DNA to identify the presence of and composition of genes in your body. After the analysis has been performed and the samples no longer needed, it will be stored as medical waste and then transferred to a third party for disposal in accordance with all local, state, and federal requirements.

It may also be the case that a biological specimen (such as blood, urine, hair, bodily fluids, etc.) from you may be deposited on medical instruments, bedding, clothing, or other objects. These objects may then be transferred to a third party for cleaning or disposal.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations as described in our Notice. You consent to the transfer of all biological specimens collected by or deposited with RDV Sportsplex Pediatrics to a third party as set forth above. This consent does not authorize the sale or transfer of a biological specimen for the purpose of DNA analysis.

You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.

My signature below indicates that I have been given the opportunity to review a current copy of RDV Sportsplex Pediatrics "Notice of Privacy Practices."