Notice of Privacy Practices for Pediatric Care

[Practice Name] Pediatrics

Effective Date: [Date]

This notice describes how medical information about your child may be used and disclosed and how you can access this information. Please review it carefully.

Our Commitment to Your Privacy

Our practice is dedicated to maintaining the privacy of your child's protected health information (PHI). We are required by law to maintain the confidentiality of health information that identifies your child.

How We May Use and Disclose Your Child's Health Information

Treatment

• Share information with other healthcare providers involved in your child's care
• Coordinate services with specialists and laboratories
• Contact you about appointment reminders

Payment

• Bill and collect payment from you, your insurance company, or other third parties
• Verify insurance coverage and benefits

Healthcare Operations

• Quality assessment activities
• Employee review activities
• Training medical students
• Compliance and licensing activities

Your Rights Regarding Your Child's Health Information

1. Right to Inspect and Copy Records
2. Right to Amend
3. Right to an Accounting of Disclosures
4. Right to Request Restrictions
5. Right to Confidential Communications
6. Right to a Paper Copy of This Notice

Changes to This Notice

We reserve the right to change this notice. We will post a copy of the current notice in our facility and on our website.

Questions and Complaints

If you have any questions about this notice or would like to report a privacy concern, please contact our Privacy Officer at:

[Practice Contact Information]

Acknowledgment

I acknowledge that I have received a copy of this Notice of Privacy Practices.

Parent/Guardian Signature

Date

Patient Name