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.
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 have the right to revoke this consent, in writing,
except where we have already made disclosures in reliance on your prior consent.
Beginning December 1, 2013, RDV Sportsplex Pediatrics will be sharing our office space with Women’s & Maternity Care Specialists. Their staff will not have access to our electronic or physical medical records system. We ensure that your protected health information will remain private and will not be shared with Women’s & Maternity Care Specialists unless specifically authorized by you.
My signature below indicates that I have been given the opportunity to review a current copy of RDV Sportsplex Pediatrics "Notice of Privacy Practices," and have received notice of shared office space by Women’s & Maternity Care Specialists.