Notice of Privacy Practices
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.
We care about the privacy of your protected health information. We are required by law to notify affected individuals following a breach of unsecured protected health information.
If you have any questions regarding your privacy or any of the information contained in this Notice, please contact our Corporate Compliance Officer, Shelly Keller, 870-336-8100.
We create a record of the care and services your child and your family receive at our clinic. We need this record in order to provide care. We are required by law to maintain the privacy of your health information, abide by the terms of this Notice and provide you with this Notice. We reserve the right to change this Notice. We reserve the right to make the New Notice effective for all protected health information we maintain. A copy of our current Notice will be available and posted at the clinic.
Protected Health Information (PHI) is defined as demographics and individually identifiable health information about your child and your family and is related to the past, present or future physical or mental health conditions of your child and your family that involves providing health care services or payment.
Important Summary Information
Acknowledgement of Privacy Practices
Requirement for Written Authorization
We will generally obtain your written permission before using your health information or sharing it with others outside our group practice. You may also initiate transfer of your records to another person by completing an authorization form. If you provide us with a written authorization, you may revoke that authorization at any time, except to the extent that we have already relied upon it. To revoke an authorization, please call our Corporate Compliance Officer, Shelly Keller, 870-336-8100.
Exceptions to Requirement for Written Authorization
There are some situations when we do not need your written authorization before using your child’s or family health information or sharing it with others. These situations include treatment, payment, health care operations, an emergency, communicating with your family, and many other circumstances which are described in detail in this Notice.
Miracle Kids Success Academy is committed to protect the privacy of your family’s health care information. Some examples of the information we are protecting are as follows:
- Information about your child’s or your family’s health condition;
- Information about health care services your child or your family have received or may receive in the future;
- Geographic information (such as where you live or work);
- Demographic information (such as your face, gender, ethnicity, or marital status);
- Unique numbers that may identify you or your child (such as your social security number, driver’s licenses number, or phone number);
- Other types of information that may identify who you are.
How is this protected health information used?
MKSA will use your child’s and your family’s medical information and share it with others in order to treat your child’s and your family’s condition, obtain payment for that treatment, and run the practices’ normal business operations. Here are some specific examples of how we may use this information without your authorization:
Health Care Operations
As Required by Law
Abuse or Neglect
Food and Drug Administration
Coroners, Funeral Directors, and Organ Donation
National Security and Intelligence Activities or Protective Services
Required Uses and Disclosures
A SUMMARY OF YOUR RIGHTS
All of your rights may be exercised by contacting the Corporate Compliance Officer of Miracle Kids Success Academy – Shelly Keller, 870-336-8100.
- You have a right to request restrictions on our use or disclosure of your child’s or your family’s protected health information. However, we are not required to agree to your restrictions. If we do not agree to your restrictions, we will follow your request, except in the case of emergency. However, if your restriction (if agreed to) will not prevent us from releasing information as required as required by other state and federal laws. Finally, if we accept your restrictions, we have the right to terminate them by notifying you of such.
- Miracle Kids Success Academy is required to agree to a restriction of the use or disclosure of protected health information to your health plan if the disclosure is not for the purpose of carrying out payment or healthcare operations and is not otherwise required by law. You may also request a restriction of protected health information to your health plan with respect to health care or services for which you have paid for in full out of pocket. We must receive your request in writing in advance of the services being provided.
- You have a right to request that we communicate about your child’s or your family’s treatment and/or protected health information by alternative means or location. We are required to accept a reasonable request. We require that you make this request in writing. You may request your health information be provided in paper or electronic format.
- You have the right to ask questions and receive answers.
- You do not have to sign an authorization form; however, it may prevent us from completing a task you have requested (such as enrollment in research study or examining you or your child to create a report for your attorney)
- The use and disclosure of protected health information will only be made with your written authorization unless otherwise permitted or required by law. Use or disclosure of psychotherapy notes protected health information for marketing purposes, and disclosures that constitute the sale of protected health information will only be made with your written authorization.
- Your refusal to sign an authorization form will not be held against you.
- You may change your mind and revoke your authorization, except in as much as we have relied on the authorization until the point or as needed to maintain the integrity of a research study.
- You have the right to inspect and copy your child’s or your family’s health information, as permitted by law.
- You have the right to request amendments to your child’s or your family’s protected health information. We require that all requests for amendments be made in writing and provide a reason to support the requested amendment. Please contact the Compliance Officer for details or to exercise this right.
- You may be contacted by Miracle Kids Success Academy regarding fundraising activities. All fundraising communications will include an option to opt-out of receiving further communications.
- You have a right to an accounting of all entities that obtained information unrelated to treatment, payment or health care operations that you did not approve by an authorization (except as required by law). To request a list, contact the Compliance Officer.
- You have a right to this Notice. Any revisions to this Notice will be made available to you.
- You have the right to contract the Compliance Officer to request additional information or ask questions.
- You may complain to the Corporate Compliance Officer of Miracle Kids Success Academy by calling 870.932.3600 and to the Secretary of the Department of Health and Human Services (hhs.gov/ocr/hipaa) if you feel that your child’s or your family’s privacy rights have been violated. We will not retaliate against you for filing a complaint.
Miracle Kids Success Academy
Jonesboro South: 870-932-3600
Jonesboro North: 870-333-2600
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