TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS
DV Pediatrics uses and discloses your protected health information for treatment, payment and health care operations. Some examples of when our office may use or disclose your health care information for these purposes include:

- Sharing test results with other health care providers for confirmation of a diagnosis; - Providing your diagnosis or other information about your health to your insurance provider or our billing service to obtain payment for the health care services we provide; - Reviewing information as part of our quality improvement program.

OTHER USES AND DISCLOSURES
DV Pediatrics may also use or disclose your protected health information, in compliance with guidelines outlined by law, for the following purposes:

- Providing you with information related to your health; - Contacting you regarding appointments, information about treatment alternatives, or other health related services; - Incidental uses or disclosures (e.g., listing your name on a sign-in sheet, etc.); - Compliance with all laws (including reports of suspected abuse, neglect or violence); - Providing certain specified information to law enforcement or correctional institutions; - Providing information to a coroner, medical examiner, funeral director, or organ procurement organization; - Public health activities when requested by a public health authority or the FDA. - Responding to health oversight agencies; - Responding to court or administrative tribunal orders, subpoenas, discovery requests or other lawful process; - Research activities; - When necessary to avert a serious threat to health or safety; - Military affairs, veterans affairs, national security, intelligence, Department of State, or presidential protective service activities; - Providing information regarding your location, general condition or death to public or private disaster relief agencies; or - Informing a family member, other relative, or close personal friend when: Information is relevant to the individual’s involvement with your care; - Notification of your location, general condition or death; - To assist in your heath care (e.g., pick-up prescriptions or other documents, note follow-up care instructions, etc.).

AUTHORIZATION FOR OTHER USES
DV Pediatrics will make other uses and disclosure of your protected health information only after obtaining your written authorization. If you authorize a use not contained in this notice, you may revoke your authorization at any time by notifying us in writing that you wish to revoke your authorization.

Subject to limitations outlined by law, you have certain rights related to use and disclosure of your protected health information, including the right to:

- Request restrictions on certain uses and disclosures. However, DV Pediatrics is not obligated to agree to requested restrictions. - Receive confidential communications of protected health information. - Inspect and copy your protected health information with some limited exceptions, subject to copying fees; - Amend your health information; - Receive an accounting of disclosures of your health information; - Obtain a copy of this notice.

Subject to limitations outlined by law, DV Pediatrics has certain duties related to your protected health information, including:

- DV Pediatrics is required by law to maintain the privacy of protected health information and to provide individuals with notice of our legal duties and privacy practices with respect to protected health information. - DV Pediatrics is required to abide by the terms of the privacy notice that is currently in effect. - DV Pediatrics reserves the right to change a privacy practice described in this notice and to make such change effective for all protected health information. Revised notice will be posted in our office and available upon request.

If you believe your privacy rights have been violated, you may make a complaint by contacting DV Pediatrics, Office Manager, 2920 Marietta Hwy, Suite 142, Canton, GA 30114, 770-704-0057 or the Secretary for the Department of Health and Human Services. No individual will be retaliated against for filing a complaint.

I acknowledge that I have received a copy of this notice regarding the use and disclosure of my health information.