Our
POLICIES
VACCINATION WAIVER SIGNATURE: If your child is over the age of two years and is not up to date with standard vaccines, we will require parents or legal guardians to sign a vaccine waiver form acknowledging that they have been counseled about risks of not following the ACIP approved vaccination schedule.
No Show Fee: If your child is scheduled for a well child exam, we have set aside up to 45 minutes of time for you child. If you fail to cancel the appointment less than 24 hours in advance, fail to show up, or arrive more than 15 minutes late, you will be charged a $50 no show fee.
CoPays: should be paid at the time of the visit. There will be a $10 fee added on if we need to bill for them
Form Fees:
There is no charge for forms filled out at the time of an exam. All other forms have a $10 fee and a one week turn around time (We try to get to them sooner but there are no promises.) Rush forms will be done within 48 business hours. There is an additional fee for this.
Release of Records: We believe it is in the best interest for your child to have one primary care physician, therefore we do not share patients with other practices. If you are leaving Noe Valley Pediatrics to transfer care to another practice, we will furnish the new doctor with a complimentary detailed Health summary, growth charts and vaccination records.
A records release signals that you are no longer an active patient of Noe Valley Pediatrics. Return to the practice is not guaranteed. Readmission is contingent on the physician’s approval.
Dismissal from practice: Our office reserves the right to dismiss patients for any reason. In those rare situations, the family will be notified by certified letter. Except for unusual circumstances, we will continue to take care of acute health issues for 30 days after receipt of the letter.
Patient Privacy Policy: 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. THIS NOTICE APPLIES TO ALL OF THE RECORDS OF YOUR CARE GENERATED BY THE CENTER, WHETHER MADE BY THE CENTER OR AN ASSOCIATED ENTITY.
Our staff understands that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a medical record that details the care and services you receive. We refer to this as protected health information (PHI). We need that record in order to provide you with quality care and to comply with certain legal requirements. This notice applies to any medical records generated by our office. While we may sometimes care for you during a hospital stay the hospital may have different policies and/or procedures and a separate notice about your medical information.
TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS: The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; performing a physical examination; performing therapeutic or diagnostic tests; referring you to another doctor or clinic for additional or specialist services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health insurance coverage or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). “Health care operations” mean those administrative and managerial functions that we have to do in order to run the Practice or the Center more efficiently and make sure that all of our patients receive quality care. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; reviewing our treatment and services to evaluate the performance of our staff; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.
In order to maintain the communications that allow for quick, effective, and high quality health care, we may release medical information about you to a family member or friend who accompanies you to your appointment unless you tell us not to.
Under most circumstances, we are not required to obtain a signed consent for Treatment, Payment, or Operations. However, we will ask you to sign an authorization for certain purposes such as release of PHI to a referring provider or for claims payment in order to comply with regulations.
We routinely use your health information inside the Practice and/or the Center for these purposes without any special permission. We will ask for special written permission in the following situations: research, legal requests, and marketing. We will also ask for your written authorization before we disclose PHI that pertains to HIV, AIDS, mental health treatment or substance abuse.
USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION: In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office or Center at all. Such uses or disclosures are:
- When a state or federal law mandates that certain health information be reported for a specific purpose;
- For public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the Federal Food and Drug Administration regarding drugs or medical devices;
- Disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
- Uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
- We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
- Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at the Center; or to report a crime that happened somewhere else;Disclosure to a correctional institution or law enforcement officials if you are an inmate or under the custody of a law enforcement official;Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
- Uses or disclosures for health related research;
- Uses and disclosures to prevent a serious threat to health or safety;
- Uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
Disclosures of de-identified information: Disclosures of a “limited data set” for research, public health, or health care operations;
Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
Disclosures to “business associates” who perform health care operations for us and who commit to respect the privacy of your health information.
APPOINTMENT REMINDERS: We may call, write, or email to remind you of scheduled appointment that it is time to make a routine appointment or to follow up after a procedure. We may also call or write to notify you of other treatments or services available at our Center that might help you. Unless you object, this contact may be on an answering machine or other method, which could (potentially) be received or intercepted by others. This call or message may be to a home or work number. In writing, you can ask us to use other methods and we will consider your request and determine our ability to comply.
OTHER USES AND DISCLOSURES: We will not make any other uses or disclosures of your health information unless you sign a written “authorization form.” Federal law determines the content of an “authorization form”. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it is your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form or you can use one of ours.
If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign the authorization, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the contact person named at the beginning of this Notice.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION: The law gives you many rights regarding your health information.
Restrictions: You can ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the contact person at the address shown at the beginning of this Notice.
Communications: You can ask us to communicate with you in a confidential way, such as phoning you at work rather than at home, by mailing health information to a different address, or, at some point in the future, we may be able to email to your personal email address. We will accommodate these requests if they are reasonable and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the contact person at the address shown at the beginning of this Notice.
Photocopies: You can ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or receiving a copy of your health information. For the most part, however, you will be able to review or receive a copy of your health information within 30 days of asking us (or sixty days if the information is stored off-site). You will be asked to pay a reasonable charge in advance for such access or copies. If we deny your request, we will send you a written explanation and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30-day extension of the time for us to give you access or photocopies if we send you a written notice of extension. If you want to review or get photocopies of your health information, send a written request to the contact person at the address shown at the beginning of this notice.
Amendments: You can ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information and others that you specify. If we do not agree, you can write a statement of your position and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have on 30-day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the office contact person at the address shown at the beginning of this Notice.
Disclosures: You can get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment, or health care operations; disclosures that were made with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30-day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the contact person at the address shown at the beginning of this Notice.
Notice: You can get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written request to the contact person at the address shown at the beginning of this Notice.
OUR NOTICE OF PRIVACY PRACTICES: By law, we must abide by the terms of this Notice of Privacy Practices. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our Center, have copies available in our office and post it on our website.
COMPLAINTS: If you think that we have not properly respected the privacy of your health information, you are free to complain to us or to the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the contact person at the address shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.
FOR MORE INFORMATION: If you want more information about our privacy practices, call or visit the contact person at the address or phone number shown at the beginning of this Notice.