Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed and how you can get

Please review this notice carefully

This notice will be followed by all members of Tosa Pediatrics with respect to health information maintained by Tosa Pediatrics. We are required to follow everything in this notice, keep health information private, tell you about our legal duties and privacy practices, and tell you if there is a privacy breach of your health information.

Treatment: Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example: results of laboratory tests and procedures will be available to all health professionals who may provide treatment or who may be consulted by staff members.

Payment: Your health information may be used to send bills and collect payment from you, your insurance company, or other payers. For example, your health plan may request and receive information on dates of services, the services provide, and the medical condition being treated.

Health care operations: Your health information maybe used as necessary to support the day-to-day activities and management of Tosa Pediatrics. For example, we may use health information to review the quality of services, develop new programs, evaluate our performance, or for budgeting and financial reporting.

Required or permitted by law: Tosa Pediatrics is required by law to disclose your health information in

Public health agencies to control or prevent disease, injury or disability, and to report births and

The Food and Drug Administration to report certain diseases, product defects, and to track products to help with recalls. A state or federal government agency to assist with their work Respond to a court order Your court-appointed guardian or your agent under a health care power of attorney

Additional Uses of Information: Your health information will be used by our staff and/or a third party agency to send you appointment reminders.

Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization.

You have certain rights under the federal privacy standards. These include:

The right to request restrictions on the use and disclosure of your protected health information The right to receive confidential communications concerning your medical condition and

The right to inspect and copy your protected health information The right to amend or submit corrections to your protected health information The right to receive and accounting of how and to whom your protected health information has

The right to receive a printed copy of this notice The right to be notified of a breach of your information The right to complain if you believe your privacy rights have been violated. You will not be penalized or otherwise retaliated against for filing a complaint. If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining

Tosa Pediatrics 8651 W. North Ave

Right to revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain.

Acknowledgement of Receipt of Notice of Privacy Practices

Tosa Pediatrics reserves the right to modify the privacy practices outlined in the notice.