Memorial Pediatric Therapy Associates, PC is committed to protecting the privacy of your child’s health information. Our Notice of Privacy Practices (HIPAA) explains how we may use and share protected health information and describes your rights. You may view it below and request a paper copy at any time by calling 713-787-6600 or emailing dawnf@memorialpediatric.com

Notice of Privacy Practices (HIPAA)

Memorial Pediatric Therapy Associates, PC

Effective Date: January 1, 2025

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Our Commitment to Your Child’s Privacy

Memorial Pediatric Therapy Associates, PC is committed to protecting the privacy of your child’s protected health information (PHI). PHI is information that identifies your child and relates to your child’s past, present, or future physical or mental health condition, the provision of health care, or payment for health care. We are required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and applicable state laws to maintain the privacy of PHI, provide you with this Notice of our legal duties and privacy practices, and follow the terms of the Notice currently in effect.

How We May Use and Disclose Your Child’s PHI Without Your Written Authorization

We may use and disclose your child’s PHI for the purposes of treatment, payment, and health care operations, as described below:

1. Treatment

We may use and share your child’s PHI to provide, coordinate, or manage your child’s occupational therapy and related services. Under HIPAA and our practice policy, we will disclose PHI for treatment without additional written authorization only to:

• Your child’s treating physician(s)

• You, the child’s parent or legal guardian

We will communicate with you about your child’s therapy services, recommendations, scheduling, and progress as part of treatment.

Disclosures to all other individuals or entities involved in your child’s care (including therapists outside this practice, schools, early intervention programs, daycare providers, case managers, or other providers) will occur only if you have signed a separate written consent or authorization permitting us to share information with those parties.

2. Payment

We may use and disclose PHI to obtain payment for services we provide. Examples include:

• Submitting claims to your insurance company or other payer

• Verifying coverage and eligibility for benefits

• Obtaining prior authorization for services

• Billing you or a responsible party for services not covered by insurance

3. Health Care Operations

Many of our internal practice operations (such as business planning, administrative management, credentialing, licensing, compliance, and general quality improvement activities) are conducted using non-identifiable information whenever possible and typically do not require the use or disclosure of your child’s PHI.

Memorial Pediatric Therapy Associates, PC is currently a solo provider practice with no staff or contractors. Therefore, we do not use or disclose your child’s PHI for training or supervision purposes at this time.

If in the future staff or contractors are engaged, we may use or disclose limited PHI for training or supervision only as necessary, and any such use or disclosure will be limited to the minimum necessary information needed for the operational purpose, consistent with HIPAA requirements.

Other Uses and Disclosures Permitted or Required by Law

We may also use or disclose PHI without authorization when permitted or required by law, including:

• Public health and safety: To report abuse, neglect, or domestic violence; prevent or reduce a serious threat to health or safety

• Health oversight: For audits, investigations, inspections, or licensure

• Legal proceedings: In response to a court or administrative order, subpoena, or discovery request (as allowed by law)

• Law enforcement: For certain law enforcement purposes

• Workers’ compensation: As authorized by workers’ compensation laws

• Coroners, medical examiners, or funeral directors

• Research: When approved by an institutional review board or as otherwise permitted by HIPAA

Uses and Disclosures That Require Your Authorization

We will obtain your written authorization before using or disclosing your child’s PHI for purposes not described in this Notice.

Memorial Pediatric Therapy Associates, PC does not use or disclose PHI for marketing purposes and will not do so.

You may revoke an authorization in writing at any time. Revocation is not retroactive and will not affect any uses or disclosures already made in reliance on your authorization. Once PHI has been disclosed to a third party with your authorization, we cannot control how that information is used or redisclosed by that party.

Your Rights Regarding Your Child’s PHI

You have the following rights, subject to certain limitations:

• Right to inspect and obtain a copy: You may request to see or receive a copy of your child’s records (paper or electronic) within 30 days of your request.

• Right to request an amendment: If you believe information is incorrect or incomplete, you may request a correction.

• Right to an accounting of disclosures: You may request a list of certain disclosures we have made of your child’s PHI.

• Right to request restrictions: You may ask us to limit certain uses or disclosures. We are not required to agree, except when you request that we not disclose information to a health plan about services paid in full out of pocket.

• Right to request confidential communications: You may request that we contact you in a specific way (e.g., phone, email, alternate address).

• Right to a paper copy of this Notice: You may request a paper copy at any time.

To exercise these rights, please contact our Privacy Officer using the information below.

Our Duties

We are required to:

• Maintain the privacy and security of PHI

• Provide you with this Notice of our legal duties and privacy practices

• Notify you following a breach of unsecured PHI affecting your child, as required by law

• Abide by the terms of the Notice currently in effect

Changes to This Notice

We reserve the right to change this Notice at any time. Any revised Notice will apply to all PHI we maintain and will be available upon request and on our website (if applicable). The effective date will appear at the top of the Notice.

Complaints

If you believe your child’s privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services, Office for Civil Rights. You will not be retaliated against for filing a complaint.

Contact Information

Privacy Officer: Dawn Forsmith, OTR
Memorial Pediatric Therapy Associates, PC
Address: 10375 Richmond Avenue, Suite 1340, Houston, Texas 77042-4298
Phone: 713-787-6600
Email: dawnf@memorialpediatric.com

You may also contact:
U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
1-877-696-6775
https://www.hhs.gov/ocr/privacy/hipaa/complaints/

This Notice of Privacy Practices is available on our website and may be viewed electronically at any time. You may also request a paper copy from our office.