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 THIS NOTICE CAREFULLY.

Introduction
We at The Children’s OT Connection (COTC) respect every patient’s right to privacy. We are required by law to maintain the privacy of children’s protected health information (“PHI”) and to provide parents with this notice, which explains our privacy practices, how we use and disclose PHI, and your rights and our obligations concerning such uses or disclosures. We are required by law to abide by the terms of this notice.

Protected Health Information
PHI includes information that we create or receive about a child and a child’s past, present or future physical or mental health condition. It also includes information that relates to a child’s treatment or payment for the services provided to that child.

Privacy Rights of Parents and Children
Parents and legal guardians may generally exercise the rights of their minor children (under 18 years of age) including the right of access PHI. At times a minor may exercise these rights and may even legally keep information confidential from his or her parents. For example, a minor has the rights of an adult with respect to diagnosis and care of some conditions (defined by law) such as sexually transmitted disease, drug dependency, and pregnancy. In addition, minor parents who are married, have given birth to a child, or meet other legal criteria are considered “emancipated” and have the rights of an adult.

How We May Use and Disclose Your Child’s PHI
Treatment: We may use and disclose your child’s PHI to provide and coordinate their care with other providers and/or other individuals that can contribute to or are involved with your child’s care. For example, our therapists may request information from, or provide information to, your child’s pediatrician, teacher, or other therapists. In addition, we may disclose your child’s PHI to other therapists to facilitate transfer of care.

Payment:
We may use your child’s PHI to bill for our services. If you have asked us to bill your insurance carrier on your behalf, we may use and disclose your PHI to bill your health insurer.

Healthcare Operations:
We may use and disclose your child’s PHI to support the operation of our organization. These uses and disclosures are necessary to run our practice and make sure that all of our patients receive quality care. For example, we may use your child’s PHI to evaluate the performance of our staff members. We may also combine health information about many patients to decide what additional services we should offer, what services are not needed, whether certain new treatments are effective, or to compare how we are doing with others and to see where we can make improvements. We may remove information that identifies your child from this set of health information so others may use it to study healthcare delivery without learning who our specific patients are. We will obtain your consent before disclosing your child’s PHI for purposes of our healthcare operations if the law requires us to do so.

Appointment reminders:
We may use and disclose your child’s PHI to contact you and remind you of appointments. Please let us know if you do not wish to have us contact you concerning appointments, or if you wish to have us use a different telephone number or address to contact you for this purpose.

Treatment Alternatives, Benefits and Services:
We may use and disclose your child’s PHI to tell you about treatment options or other programs or services we offer that may be of interest to you.

Research:
There may be situations where we want to use and disclose health information about your child for research purposes. For example, a research project may involve comparing the efficacy of one treatment over another. For any research project that uses your health information, we will either obtain an authorization from you or ask an Institutional Review or Privacy Board to waive the requirement to obtain authorization from you. A waiver of authorization will be based upon assurances from a review board that the researchers will adequately protect your child’s health information. If the law requires us to obtain your consent, we will do so before using or disclosing your child’s PHI for research purposes.
Health Oversight: We may disclose your child’s PHI to a health oversight agency for activities authorized by law. Such activities include, for example, to license, audit or investigate healthcare providers and the healthcare system. These activities are necessary for the government to monitor the health care system, government programs and compliance with such laws as the civil rights laws.

Threats to Safety and Health:
Consistent with law, we may disclose your child’s PHI, when necessary, to avoid a serious threat to your child’s health or safety, or the health or safety of another person or the general public.

As Required by Law:
We will disclose your child’s PHI when we are required to do so by federal or state law.
Public Health Risks: We may disclose health information about your child for public health activities. These activities generally include the following:

• To prevent or control disease, injury or disability;
• To report births and deaths;
• To report child abuse or neglect;
• To report reactions to medications or problems with products;
• To notify people of recalls of products they may be using;
• 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 by law.

Law Enforcement:
In compliance with law, we may release health information if asked to do so by a law enforcement official:

• In response to a court order, subpoena, warrant, summons or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About a death we believe may be the result of criminal conduct;
• In an instance of criminal conduct at our facility; and
• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description, or location of the person who committed the crime.

Other Uses or Disclosures:
Other uses and disclosures of your child’s PHI will be made only with your written consent. You may revoke your consent at any time by notifying us in writing at compliance@cotcweb.com or COTC, Suite 200, 690 Canton Street, Westwood, MA 02090. Beginning at the time we receive your revocation, we will no longer use or disclose your child’s PHI for the purpose(s) covered in your consent, except to the extent that we have already take some action in reliance upon your consent. 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 the records of the care that we provided to your child.

Your Rights Regarding Your PHI

Right to Request Restrictions:
You may request a restriction or limitation on: (1) the PHI we use or disclose about your child for treatment, payment or healthcare operations; and/or (2) the PHI about your child we disclose to someone involved in your child’s care or the payment of their care. However, we are not required to agree to your request.

Right to Request Confidential Communications:
You may request that we communicate PHI to you in a certain way or at a certain location. For example, you may ask us to contact you only at home, or by mail. To make such a request, you must do so in writing and supply us with an alternative location or method of contact. We will accommodate all reasonable requests as long as we can easily communicate the PHI in the manner you request.

Right to Inspect and Copy:
You have the right to inspect and copy your child’s PHI for as long as we maintain it. This does not include psychotherapy notes. If you request a copy of your child’s PHI, we may charge a copying fee for it if permitted to do so by law. To inspect and copy health information relating to your child, you must submit your request in writing to us at compliance@cotcweb.com or COTC, Suite 200, 690 Canton Street, Westwood, MA 02090.

Right to Amend:
If you believe the PHI we maintain about your child is incorrect or incomplete, you may ask us to fix it. You have the right to request an amendment for as long as we keep information. In order to make such a request, you must submit your request to us in writing and tell us the reason for your request. We may deny your request for a variety of reasons. If we deny your request, we will tell you in writing the reason(s) for the denial and explain your rights regarding responding to the denial. Any amendment we make to your child’s health information will be disclosed to those with whom we disclose information as previously specified.

Right to an Accounting of Disclosures:
You have the right to request an accounting of instances in which we disclosed your child’s PHI to others, except for uses and disclosures for treatment, payment, and health care operations or that has occurred as the result of a permitted use or disclosure under law, as previously described. Also, any disclosure to you or that you authorized will not be part of the accounting. To request this list of disclosures, you must submit your request in writing at compliance@cotcweb.com or COTC, Suite 200, 690 Canton Street, Westwood, MA 02090.

Your request must state a time period that may not be longer than six years and may not include dates before January 21, 2004 (The date our company opened for business). If you ask for more than one accounting within a twelve-month period, we may charge you a fee for every accounting provided after the first one. We will notify you of the costs 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 health information we use or disclose about your child for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about your child to someone who is involved in your care or the payment for your care. For example, you could ask that access to your child’s health information be denied to a particular member of our workforce who is known to you personally.

While we will try to accommodate your request for restrictions, we are not required to do so if it is not feasible for us to ensure our compliance with law or we believe it will negatively impact the care we may provide your child. If we do agree, we will comply with your request unless the information is needed to provide your child emergency treatment. To request a restriction, you must make your request in writing at compliance@cotcweb.com or COTC, Suite 200, 690 Canton Street, Westwood, MA 02090 .In your request, you must tell us what information you want to limit and to whom you want the limits to apply.

Right to a Paper Copy of This Notice:
You have a right to a paper copy of this notice even if you originally agreed to receive it electronically. You may request a paper copy at any time.

Changes to This Notice:
We reserve the right to change this notice and to do so without advance information or consent. Any revised version of this notice will be effective for all PHI that we maintain about your child, including information created prior to the effective date of the revision. Upon your request, we will provide you with a copy of the most up-to-date version of this notice. We will also post a copy of the current Notice in our office and on our website at http://www.cotcweb.com. This Notice contains the effective date on the last page.

Questions and Complaints:
If you wish to exercise any of the rights explained in this notice, have any questions about this notice, believe we have violated your child’s privacy rights, or wish to file a complaint, please contact our Privacy Officer at 781-915-0299, compliance@cotcweb.com, or mail to: COTC, Suite 200, 690 Canton Street, Westwood, MA 02090. You can also file a written complaint with the United States Department of Health and Human Services. You will not be penalized in any way for filing a complaint.

This notice is effective as of January 20, 2004.