Privacy Form


Our Practice recognizes and respects the fact that the patient/parent has right to inspect and obtain a copy of his/her child’s Protected Health Information (PHI).

Uses and Disclosures of Protected Health Information:

We will use and disclose your protected information to provide, coordinate or manage health care and any related services.

Examples: Information sent to another provider to whom your child has been referred, emergency treatment situations, public health authority, Workmen’s Compensation, Legal Investigative units or other legal entities.
Protected health information will be used as needed to obtain payment for services.
Information required by school, day care, camp or sports organizations regarding the health status of a child for the child’s participation and attendance
We may disclose protected health information in order to support business activities.

Examples: Quality assessment, liability insurance coverage, medical review, underwriting, licensing, employee review and billing or health insurance audits, investigations or inspections.
Signed request for records by parent or guardian for personal use or to be sent to an outside source. Char copies carry a charge for copying and postage
Parent or guardian has the right to:

  • Request that certain parts of the patient charting information NOT be copied or disclosed to outside sources. Specific restriction must be stated in writing. Provider is not required to agree to restriction if best interest of patient is not represented by withholding specified information.
  • Request to review (by appointment only and in presence of office employee) charting information belonging to their child. Copies of charting information may be requested in writing and supplied at a charge by physician’s office.
  • Request that any incorrect charting information be amended by the medical office staff as agreed upon by the provider. Parent and provider should initial amended portions.
  • Restrict all copying and disclosure of patient’s sharing information. This would mean that we could not bill insurance carriers. We would also be unable to fill out any forms or copy charts. Office is not required to agree to this restriction as it may apply to protecting the welfare of a child under child protection laws which supersede this agreement. (Should patient ask that NO information be released to any outside agency, parent must present a written notice signed by the parent/guardian).

Parent/Guardian Responsibilities:

  • Provide and keep office updated with current insurance and demographic information
  • Contact insurance carrier or workplace benefits coordinator for clarification of coverage
  • Pay for services not included as benefits by office-contracted insurance carrier
  • Pay for services in full ins insurance is not contracted by office or self-pay status
  • Understand that office can only bill diagnosis as documented in patient record. Office will not charge or fraudulently falsify a diagnosis to secure insurance payment
  • Submit a written request for transfer of records when required. Records are destroyed following approved clinical/legal guidelines


Peep Privacy Hippa Doc

Peep Protected Health Information

  • My signature on this document implies that I have read and understood it’s contents. I am giving my consent to this office to release information as specified above. I may rescind my consent in writing at any time.