Child Intake Form

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

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal programthat requires that all medical records and other individually identifiable health informationused or disclosed by us in any form, whether electronically, on paper, or orally, are keptproperly confidential. This Act gives you, the patient, significant new rights to understand andcontrol how your health information is used. We are required by law to maintain the privacyof your protected health information and to provide you with notice of our legal duties andprivacy practices with respect to protected health information. HIPAA provides penalties forcovered entities that misuse personal health information.As required by HIPAA, we have prepared this explanation of how we are required to maintain theprivacy of your health information and how we may use and disclose your health information.Treatment means providing, coordinating, or managing health care and related services, by oneor more health care providers. An example of this would include a physical examination.Payment means such activities as obtaining reimbursement for services, confirming coverage,billing or collections activities, and utilization review. An example of this would be sending abill for your visit to your insurance company for payment.Health care operations include the business aspects of running our practice, such as conductingquality assessment and improvement activities, auditing functions, cost-management analysis,and customer service. An example would be an internal quality assessment review.We may create and distribute de-identified health information by removing all references toindividually identifiable information.We may contact you to provide appointment reminders or information about treatmentalternatives or other health-related benefits and services that may be of interest to you.Any other uses and disclosures will be made only with your written authorization. You mayrevoke such authorization in writing and we are required to honor and abide by that writtenrequest, except to the extent that we have already taken actions relying on your authorization.You have the following rights with respect to your protected health information, which youcan exercise by presenting a written request to the Privacy Officer:The right to request restrictions on certain uses and disclosures of protected health information,including those related to disclosure to family members, other relative, close personal friends,or any other person identified by you. We are, however, not required to agree to a requestedrestriction. If we do agree to a restriction, we must abide by it unless you agree in writing toremove it.The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.The right to inspect and copy your protected health information.The right to amend your protected health information.The right to obtain a paper copy of this notice from us upon request.This notice is effective as of April 14, 2003 and we are required to abide by the terms of theNotice of Privacy Practices currently in effect. We reserve the right to change the terms of ournotice of Privacy Practices and to make the new notice provisions effective for all protectedhealth information that we maintain. We will post and you may request a written copy of arevised Notice of Privacy Practices from this office.You have recourse if you feel that your privacy protections have been violated. You have theright to file written complaints with our office, or with the Department of Health & HumanServices, Office of Civil Rights, about violations of the provisions of this notice or the policesand procedures of our office. We will not retaliate against you for filing a complaint.Please contact the following for more information:The U.S. Department of Health & Human ServicesOffice of Civil Rights200 Independence Avenue, S.W.Washington, D.C. 20201(202) 619-0257Toll Free: 1-877-696-6775

Keys To Communicate is required by law to keep your health information and records safe. This information may include: Notes from your doctor, teacher or other healthcare provider, Medical history, Test results, Treatment notes, Insurance information. We are required by law to give you a copy of our privacy notice. This notice tells you how your health information maybe used and shared. The below signature shows that you acknowledge that you have received a copy of Keys To Communicate's HIPAA Notice of Privacy Practices that fully explains the uses and disclosures they will make with respect to my individually identifiable health information. It acknowledges you have had the opportunity to read the notice and to have any questions regarding the notice answered to my satisfaction. You understand Keys To Communicate cannot disclose my health information other than as specified in the notice. By signing below, you understand that Keys To Communicate reserves the right to change the notice and the practices detailed therein if it sends a copy of the revised notice to the address I have provided.