Health Insurance Portability and Accountability Act of 1996

Dear Parent or Legal Guardian,

When reading this notice it is understood that we are talking about our patients who are mostly minors, your child(ren) “You” defined hereinafter as the patient, and if a minor, the parent or legal guardian.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. THIS NOTICE IS EFFECTIVE APRIL 14, 2003 .

If you have any questions about this notice, please contact our Privacy Officer at (305) 696-9490 or email us at info@rubpediatrics.com.

- Any healthcare professional authorized to enter information into the patient’s chart.

- Any referring healthcare specialist or hospital with entity that you’ve consulted with.

All these covered entities, sites and locations follow the terms of this notice. In addition, these entities, sites and locations may share medical information with each other for purposes described in this notice.

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive in our office each time you visit. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by our office or records you brought from a previous doctor. We are not responsible for HIPAA compliance for any medical records prior to coming to our office.

This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of your medical information.

- Give you this notice of our legal duties and privacy practices with respect to medical information about you.

The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, nurse practitioners, medical assistants, technicians, medical students, or other office personnel involved in taking care of you in our office. We also may disclose medical information about you to people outside the office who may be involved in your medical care after you leave our office including, but not limited to, immediate family members, laboratories, pharmacists, specialist doctors, hospitals or others we use to provide services that are part of your care.

We may use and disclose all necessary medical information about you so that the treatment and services you receive at our office may be billed to and payment may be collected from you, your insurance company, or a third party. For example, we may need to give your health plan information about immunizations you received in our office so that your health plan will pay us or reimburse you for these immunizations. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. We may disclose all necessary medical information about you to a collection agency in order to receive payment reimbursement for treatment and services provided to you.

We may use and disclose medical information about you for all office operations. These uses and disclosures are necessary to run the office and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services to evaluate the performance of our staff in caring for you. We may also combine medical information about many patients to decide what additional services our office should offer, what services are not needed, whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical assistants, medical students, ancillary services, or hospital personnel for review and learning purposes.

We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the office.

We may use & disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

We may use and disclose information to tell you about health-related benefits or services that may be of interest to you.

We will disclose medical information about you when required to do so by federal, state, or local law.

We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat such as the Health Dept.

We may disclose your health information to individuals, such as family members and friends, who are involved in your care or who help pay for your care. We may make these disclosures when (a) we have your verbal permission to do so; (b) we make such disclosures and you do not object; or (c) we can infer from the circumstances that you would not object to such disclosures. For example, if you send a nanny or grandparent to take your child to our office for a doctor’s visit, we will assume that you agree to our disclosure of your child’s information in their presence.

SPECIAL SITUATIONS

If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary.

We may disclose medical information about you for public health activities. These activities generally include the following:

- To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.

- To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence, as required or authorized by law.

- To notify parent, law enforcement or any appropriate agency in case of life or death threatening situation to procure proper help.

We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government programs, and compliance with civil right laws.

If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

We may release medical information if asked to do so by law enforcement official:

- To identify or locate a suspect, fugitive, material witness, or missing person.

- About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement.

- In emergency circumstances to report a crime, the location of a crime or victims, or the identity, description or location of the person who committed the crime.

We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

If you are appointed a legal guardian by the courts, we may release medical information to the courts or the legal guardian institution to which you are appointed.

You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to Rub Pediatrics M.D., P.A 21110 Biscayne Blvd. Ste. 308 Aventura, FL. 33180. If you request a copy of the information, we may charge a fee for the costs of copying (according to Florida Administrative Code 21M-26.003), mailing or other supplies associated with your request, which is payable at time these services are rendered.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by Rub Pediatrics M.D. PA will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Inspect and Copy. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to make an addendum to the information to correct or complete it. You have the right to request an amendment for as long as the information is kept by or for Rub Pediatrics M.D. PA.

To request an amendment, your request must be made in writing and submitted to Rub Pediatrics M.D, P.A. 21110 Biscayne Blvd. Ste. 308 Aventura , FL 33180 . We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

- Was not created by us, unless the person or entity that created the information is no longer available to make the amendment.

- Is not part of the information which you would be permitted to inspect and copy; or

Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you.

To request this list or accounting of disclosures, you must submit your request in writing to Rub Pediatrics M.D. PA, 21110 Biscayne Blvd. Ste. 308 , Aventura , FL 33180 . Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003 . Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be complimentary. For additional lists or if you lost your list, we may charge you for the costs of providing the additional lists. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. However, our notes include all of the following components that can not be separated: history, physical exam, diagnosis and treatment.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing to Rub Pediatrics M.D, P.A. 21110 Biscayne Blvd. Ste. 308 , Aventura , FL 33180 . In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to other immediate family members.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to Rub Pediatrics M.D, P.A. 21110 Biscayne Blvd. Ste. 308 , Aventura , FL 33180 . We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice on our website http://rubpediatrics.com. To obtain a paper copy of this notice, you may stop by any of our office locations.

We reserve the right to change this notice at any time without warning. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our office and on our website. The notice will contain on the first page, the effective date. In addition, each time you visit our office, you may request a copy of the current notice in effect.

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact our Privacy Officer at (305) 696-9490. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Other Uses of Medical Information. Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you. Additionally, if you revoke your permission, we may choose to ask that you seek medical advice from another physician.

RUB PEDIATRICS MD PA

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

NOTICE OF PRIVACY PRACTICES