NOTICE OF PRIVACY PRACTICESFOR PROTECTED HEALTH INFORMATION

Effective date: April 14, 2003

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.

If you have any questions or wish to receive additional information about the Matters covered 

by this Notice of Privacy Practices, please contact Sally Katz at 585-244-5200.

 

Sunrise Pediatrics, LLP is required to abide by the terms of this Notice of Privacy Practices (this 

notice). Sunrise Pediatrics reserves the right to change the terms of this Notice at any time. The revised 

Notice will apply to all protected health information Sunrise Pediatrics receives or creates in the future. 

A current copy of the Notice will be posted in the billing office and on the website. The effective date of 

this Notice of Privacy Procedures is set forth on the first page of this Notice. If this Notice of Privacy 

procedures has been changed since your last appointment, Sunrise Pediatrics will provide a copy of the 

current Notice of Privacy Practices to you when you sign in for your appointment. Additionally, you may 

obtain a copy of the current Notice by calling your physician and requesting that one be sent to you in 

the mail or by asking for one when you are in the office.

 

Your “protected health information” consists of all individually identifiable information which is 

created or received by Sunrise Pediatrics and which relates to your past, present, or future physical or 

mental health condition, the provision of health care to you, or the past, present, or future payment for 

 

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR WHICH YOUR CONSENT OR 

 

Treatment: Sunrise Pediatrics will use your protected health information to provide, coordinate or 

manage your health care and related services by Sunrise Pediatrics and other health care providers, 

including consulting with other health care providers about your health care or referring you to another 

health care provider for treatment. For example, Sunrise Pediatrics will disclose your protected health 

information to a specialist to whom you have been referred to ensure that the specialist has the 

necessary information he or she needs to diagnose and/or treat you.

 

Payment: Sunrise Pediatrics will use and disclose your protected health information, as needed, to 

obtain payment for the health care Sunrise Pediatrics provides to you. For example, prior to providing 

services, Sunrise Pediatrics may disclose to your insurance carrier the treatment you are going to receive 

to ensure that your insurance carrier will cover that treatment. Additionally, Sunrise Pediatrics may 

disclose to your insurance carrier, as necessary, the treatment you received to ensure that Sunrise 

Pediatrics is paid or you are reimbursed for the cost of your treatment.

 

Health Care Operations: Sunrise Pediatrics may use or disclose your protected health information 

in order to support the business activities of Sunrise Pediatrics. These activities include, but are not 

limited to, quality assessment and improvement activities, reviewing the competence or qualification of 

health care professionals, conducting training programs in which students provide treatment under the 

supervision of one of Sunrise Pediatrics’ physicians, business planning and development and business 

management and general administrative activities. For example, Sunrise Pediatrics may disclose 

your protected health information to medical school students that see patients of Sunrise Pediatrics. 

Additionally, Sunrise Pediatrics may use your protected health information to ensure that all of the 

physicians at Sunrise Pediatrics provide the highest quality health care.

 

Appointment Reminders: Sunrise Pediatrics may use or disclose your protected health information in 

order to contact you and remind you of a scheduled appointment.

 

Treatment Alternatives: Sunrise Pediatrics may use or disclose your protected health information to 

inform you about treatment alternatives.

 

Health Related Benefits and Services: Sunrise Pediatrics may use or disclose your protected health 

information to inform you about health-related benefits and services that may be of interest to you.

 

Fundraising Activities: Sunrise Pediatrics may use or disclose your protected health information to raise 

funds for Sunrise Pediatrics. Specific permission will be obtained prior to all fund raising activities. This 

Notice of Privacy Practices does not constitute that permission.

 

Others Involved in Your Health Care and Disaster Relief: Unless you object, Sunrise Pediatrics may 

disclose to a family member, other relative, close personal friend or any other person identified by 

you, protected health information related to that person’s involvement in your health care or payment 

related to your health care. Sunrise Pediatrics may also use or disclose to a person responsible for your 

care your protected health information that relates to your location, general condition or death. If the 

opportunity for you to agree or object to any such disclosure cannot be provided due to emergency 

circumstances, Sunrise Pediatrics will make these disclosures if they are in your best interests. 

Additionally, Sunrise Pediatrics may disclose protected health information relating to your location, 

general condition or death to any public or private entity authorized to assist in disaster relief efforts.

 

Public Health: Sunrise Pediatrics may disclose your protected health information to a public health 

authority authorized to collect such information for the purpose of:

A: preventing or controlling disease, injury, or disability;

B: reporting disease or injury;

C: reporting vital events such as births or deaths;

D: conducting public health surveillance, public health investigations and public health 

E: at the discretion of a public health authority, to an official of a foreign government agency 

acting in collaboration with a public health authority; or

F: reporting child abuse or neglect.

 

Food and Drug Administration: Sunrise Pediatrics may disclose your protected health information to a 

person subject to the jurisdiction of the Food and Drug Administration (FDA) for the purpose of activities 

related to the quality, safety or effectiveness of FDA regulated products.

 

Communicable Diseases: Sunrise Pediatrics may disclose your protected health information, if 

authorized by law, to a person who may have been exposed to a communicable disease or may 

otherwise be at risk of spreading a disease or condition.

 

Employer: Sunrise Pediatrics may disclose your protected health information to your employer 

if Sunrise Pediatrics is providing health care to you at the request of your employer to conduct an 

evaluation relating to medical surveillance relating to your workplace or to evaluate whether you have a 

 

Abuse, Neglect, or Domestic Violence: Sunrise Pediatrics may disclose your protected health 

information to a government authority authorized to receive reports of abuse, neglect, or domestic 

violence. Any such disclosure will be made (1) to the extent it is required by law, (2) to the extent that 

the disclosure is authorized by statute of regulation and Sunrise Pediatrics believes the disclosure is 

necessary to prevent serious harm to you or other potential victims or (3) if you agree to the disclosure.

 

Health Oversight Activities: Sunrise Pediatrics may disclose your protected health information to a 

health oversight agency for any oversight activities authorized by law, including audits; investigations; 

licensure or disciplinary actions; civil, criminal or administrative actions or proceedings; or other 

activities necessary for the oversight of the health care system, government benefit programs, 

compliance with government regulatory program standards or compliance with applicable civil rights 

 

Judicial and Administrative Proceedings: Sunrise Pediatrics may, upon certain conditions, disclose your 

protected health information in the course of any judicial or administrative proceeding in response to an 

order of a court or administrative tribunal, a subpoena, discovery request, or other lawful process.

 

Law Enforcement Purposes: Sunrise Pediatrics may disclose your protected health information for law 

enforcement purposes to a law enforcement official:

A: in compliance with a court order, a court-ordered warrant, a subpoena or summons issued 

by a judicial officer or an administrative request;

B: in response to a request for information for the purpose of identifying or locating a suspect, 

fugitive, material witness or missing person;

C: in response to a request about an individual that is suspected to be a victim of a crime, if, 

under limited circumstance, Sunrise Pediatrics is not able to obtain your consent;

D: if the information relates to a death Sunrise Pediatrics believes may have resulted from 

E: if the information constitutes evidence of criminal conduct that occurred on the premises of 

F: in certain emergency circumstance, to alert law enforcement of the commission and nature 

of a crime, the location and victims of the crime and the identity, or description and location of 

the perpetrator of the crime.

 

Coroners, Medical Examiners and Funeral Directors: Sunrise Pediatrics may disclose your protected 

health information to a coroner or medical examiner for the purpose of identifying you, determining 

a cause of death or other duties authorized by law. Sunrise Pediatrics may disclose your protected 

health information to a funeral director, consistent with all applicable laws, in order to allow the funeral 

director to carry out his or her duties.

 

Organ and Tissue Donation: Sunrise Pediatrics may disclose your protected health information 

to organ procurement organizations or other entities engaged in the procurement, banking, or 

transplantation of organs, eyes, or tissue for the purpose of facilitating organ, eye, and tissue donation 

 

Medical Research: Sunrise Pediatrics may disclose your protected health information for research 

purposes, provided that an institutional review board authorized by law or a privacy board waives the 

authorization requirement and provided that the researcher makes certain representations regarding 

the use and protection of the protected health information to be disclosed.

 

Serious Threat to Health or Safety: Sunrise Pediatrics may disclose your protected health information, 

in a manner which is consistent with applicable laws, if the disclosure is necessary to prevent or lessen a 

serious threat to health or safety or the information is necessary to apprehend an individual.

 

Military and Veterans Activities: Sunrise Pediatrics may, if you are a member of the United States 

or foreign Armed Forces, disclose your protected health information for activities that are deemed 

necessary by appropriate military command authorities to assure the proper execution of a military 

 

National Security and Protection of the President and Others: Sunrise Pediatrics may disclose your 

protected health information to authorized federal officials for the conduct of lawful intelligence, 

counter-intelligence and other national security activities authorized by law. Additionally, Sunrise 

Pediatrics may disclose your protected health information to authorized federal officials for the 

provision of protective services to the President, foreign heads of state, or other people authorized by 

law and to conduct investigations authorized by law.

 

Inmates: Sunrise Pediatrics may disclose your protected health information to a correctional institution 

or a law enforcement official having lawful custody of you if the correctional institution or law 

enforcement official represents that the information is necessary to (1) provide health care to you; (2) 

the health and safety of other inmates; (3) the health and safety of the officers and employees of the 

correctional institution or the people responsible for transporting the inmates (4) law enforcement on 

the premises of the correctional institution; or (5) the administration and maintenance of the safety, 

security and good order at the correctional institution.

 

 Workers’ Compensation: Sunrise Pediatrics may disclose your protected health information as 

authorized by, and in compliance with, laws relating to workers’ compensation and other similar 

programs established by law that provide benefits for work-related illnesses and injuries without regard 

 

OTHER USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Any use or disclosure of your protected health information that is not listed above will be made only 

with your written authorization. You have the right to revoke your authorization at any time, except 

to the extent that Sunrise Pediatrics has already used or disclosed your protected health information in 

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

Restriction of Use and Disclosure: You have the right to request that Sunrise Pediatrics restrict the 

protected health information Sunrise Pediatrics uses and discloses in carrying out treatment, payment 

and health care operations. You also have the right to restrict the protected health information Sunrise 

Pediatrics discloses to a family member, other relative or any other person identified by you, which 

is relevant to such person’s involvement in your treatment or payment for your treatment. SUNRISE 

PEDIATRICS IS NOT OBLIGATED TO AGREE TO ANY RESTRICTION THAT YOU REQUEST. If Sunrise 

Pediatrics agrees to a restriction, however, Sunrise Pediatrics may only disclose your protected health 

information in accordance with that restriction, unless the information is needed to provide emergency 

health care to you. If you wish to request a restriction on the use and disclosure of your protected 

health information, please send a written request to the Privacy Officer which specifically sets forth (1) 

whether you are restricting the use or the disclosure of your protected health information, (2) what 

protected health information you wish to limit, and (3) to whom you wish the limits to apply (i.e., your 

spouse). Sunrise Pediatrics will not ask why you are requesting the restriction. The privacy officer 

will review your request and notify you whether or not Sunrise Pediatrics will agree to your requested 

 

Confidential Communications: You have the right to request that you receive communications of your 

protected health information from Sunrise Pediatrics in alternative means or at alternative locations. 

Sunrise Pediatrics will accommodate all reasonable requests. To request that Sunrise Pediatrics make 

communications of your protected health information by alternative means or at alternative locations, 

please send a written request to the Privacy Officer setting forth the alternative means by which you 

wish to receive communications. Sunrise Pediatrics will not ask why you are making such a request. 

When appropriate, Sunrise Pediatrics may condition the provision of a reasonable accommodation upon 

receiving information relating to how payment, if any, will be received.

 

Access to Protected Health Information: You have the right to inspect and obtain a copy of your 

protected health information that Sunrise Pediatrics maintains in a designated record set, for so long as 

that protected health information is maintained in a designated record set. A “designated record set” 

is a group of records maintained by or for Sunrise Pediatrics which includes billing records and records 

used in whole or in part to make decisions about you. You do not have the right to inspect or copy 

psychotherapy notes, information compiled in reasonable anticipation of, or for use in, a civil, criminal 

or administrative action or proceeding, or information that Sunrise Pediatrics is otherwise prohibited 

by law from disclosing. If you wish to inspect or obtain a copy of your protected health information, 

please send a written request to the Privacy Officer. If you request a copy of your protected health 

information, Sunrise Pediatrics may charge a fee for the cost of copying and mailing the information. 

Sunrise Pediatrics may, for certain limited reasons, deny your request to inspect or obtain a copy of your 

protected health information. If Sunrise Pediatrics denies your request, you may be entitled to a review 

of that denial. If you are entitled to a review and you wish to have Sunrise Pediatrics’ decision reviewed, 

please contact the Privacy Officer. The Privacy Officer will designate a licensed health care professional 

to review your request. This reviewing health care professional will not have participated in the original 

decision to deny your request. Sunrise Pediatrics will comply with the decision of the reviewing health 

 

Amending Protected Health Information: You have the right to request that Sunrise Pediatrics amend 

your protected health information in a designated record set for so long as that information exists in a 

designated record set. To request that an amendment be made to your protected health information, 

please send a written request to the Privacy Officer. Your written request must provide a reason that 

supports the requested amendment. Sunrise Pediatrics may deny your request if it does not contain 

a reason that supports the requested amendment. Additionally, Sunrise Pediatrics may deny your 

request to have your protected health information amended if Sunrise Pediatrics determines that 

(1) the information was not created by Sunrise Pediatrics, unless the person or entity that created 

the information is no longer available to make the amendment; (2) the information is not part of a 

designated record set; (3) the information is not available for your inspection; or (4) the information is 

 

Accounting of Disclosures of Your Protected Health Information: You have the right to request a listing 

of certain disclosures of your protected health information made by Sunrise Pediatrics during the period 

of up to six (6) years prior to the date on which you make your request. Any accounting you request 

will not include (1) disclosures made to carry out treatment, payment or health care operations; (2) 

disclosures made to you; (3) disclosures made pursuant to an authorization given by you; (4) disclosures 

made to other people involved in your care or made for notification purposes; (5) disclosures made 

for national security or intelligence purposes; (6) disclosures made to correctional institutions or law 

enforcement officials; or (7) disclosures made prior to April 14, 2003. The right to receive an accounting 

is subject to certain other exceptions, restrictions and limitations set forth in applicable statutes and 

regulations. To request an accounting of the disclosures of your protected health information made by 

Sunrise Pediatrics, please send a written request to the Privacy Officer. Your written request must set 

forth the format in which you want the accounting. Sunrise Pediatrics will provide one free accounting 

during each twelve (12) month period. If you request additional accountings during the same twelve 

(12) month period, you will be charged for all costs Sunrise Pediatrics incurs in preparing and providing 

that accounting. Sunrise Pediatrics will inform you of the fee for each accounting in advance and will 

allow you to modify or withdraw your request in order to reduce or avoid the fee.

 

Obtaining a Copy of this Notice: You have the right to request and receive a paper copy of this Notice of 

Privacy Practices from Sunrise Pediatrics at any time. 

 

If you believe that your privacy rights have been violated, you may file a complaint with Sunrise 

Pediatrics or with the Secretary of Health and Human Services. To file a complaint with Sunrise 

Pediatrics, please contact Sally Katz at 585-244-5200. All complaints must be submitted in writing. 

SUNRISE PEDIATRICS WILL NOT RETALIATE AGAINST YOU FOR FILING A COMPLAINT.