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Notice of Privacy Practices




As Required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act (HIPAA) and the HITECH Act



Our Commitment to your privacy

Rivergate Pediatrics is dedicated to maintaining the privacy of “Personal Health Information” (PHI), which is information that identifies our patients and includes their medical history.  In this notice, “you” is meant to refer to the patient and/or personal representative (parent, legal guardian, or responsible party).

          This notice will tell you:

  • Ways in which we may use and disclose medical information about you.
  • How we may access your medical information from other sources
  • How we may share your medical information with other providers
  • Our obligations concerning the use and disclosure of your PHI.
  • How we deal with confidentiality for minors (older children and teens).
  • Your privacy rights concerning your PHI.

You will be offered a copy of this notice on your first visit to Rivergate Pediatrics on or after April 14th, 2003 and will be asked at that time to acknowledge in writing that you received a copy of our “Notice of Privacy Practices.”

The terms of this notice apply to all records containing PHI that are created or retained by our practice, including electronic records.  We reserve the right to revise or amend this Notice of Privacy Practice.  Any revision or amendment of this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future.  Our practice will post a copy of our current Notice in our waiting room, and you may request a copy of our most current Notice at any time.

If you have questions about this notice, please contact Rivergate Pediatrics, P.C. Administrator at 807 Meadow Lark Lane, Goodlettsville, TN, 37072. 615-859-6650

The following categories describe different ways we use and disclose your PHI.

  • For Treatment.  Rivergate Pediatrics may use your PHI to provide you with medical treatment or services.  We may ask you to have lab test or send you for x-rays and use the results to help us reach a diagnosis.  We may use your PHI to write a prescription and we may disclose your PHI to a pharmacy when we order a prescription for you.  Many of the people that work for Rivergate Pediatrics may use or disclose your PHI in order to treat or assist others in your treatment.  We may also disclose your PHI to others that may assist in your care, such as family members. We may access your PHI from other sources (hospitals, pharmacies, other doctors) through secure electronic communication, as part of providing medical treatment and we may share some of your PHI from Rivergate Pediatrics over the same networks to facilitate treatment, payment, and operations by your other providers.  PHI which we use or disclose for Treatment will include identifying demographic information and complete medical information.
  •  For payment.  Rivergate Pediatrics may use and disclose your PHI in order to bill and collect payment from you, an insurance company, or a third party for the services and treatment you receive from us.  For example, we may contact your health insurance plan to verify coverage, or make referrals, and provide details regarding your treatment to determine your health insurance coverage.  We may provide your PHI to an electronic billing service to aid in collecting payment.  Also, if need be, we may provide this information to a collection agency. PHI which we use or disclose for Payment will be limited to the information required by an insurance company or third party to bill and collect payment for services and treatment you receive from us. You can limit disclosure to an insurance company if YOU pay for services in full.
  • For Health Care Operations.  Rivergate Pediatrics may use your PHI to assess our practice and   business operations.  For example, we may use your PHI to compile reports of certain procedures our physicians perform monthly or yearly.  We may use your PHI to evaluate the quality of care you receive from us and to conduct cost-management and business planning activities for our practice.  We may also use your PHI to share with business associates as necessary for quality assessment, quality improvement, training programs, credentialing, medical review, legal services, and insurance.  Your information may be shared with health care providers and their authorized representatives that are members of an Organized Health Care Arrangement (OHCA) in which this practice participates for the purposes of utilization review, quality assessment, and quality improvement. You may request limitations to this use.
  • Phone Communication.   Rivergate Pediatrics may use and disclose your PHI when contacting you by phone. At your initial visit and during annual updates of your demographic data, you will be asked for contact phone numbers.  You will be asked if it is okay to leave messages at these numbers.  If you authorize messages to be left at your contact phone numbers Rivergate Pediatrics may:
    • leave messages to remind you of an upcoming appointment
    • leave a message re: a change in appointment
  • provide information needed for a referral appointment, scheduled x-ray or lab test

(messages may include date, time, location and physician for appointment)

    • notify you that a refill order has been sent to your pharmacy per your request
    • notify you of results for routine screening tests, normal labs and x-rays
  • leave a message with a close family member, after asking them to identify themselves

Messages left on unidentified voice mailboxes and messages about sensitive information will only ask for a return call. You can ask for restrictions or limitations to our phone policy by requesting and filling out a Request for Limitations and Restrictions form. For more information see the Your Rights Regarding your PHI below.

  • Treatment Options and Health Related Benefits and Services.  Rivergate Pediatrics may use and disclose your PHI to inform you of potential treatment options or alternatives and to inform you of health-related benefits and services that may be of interest to you. If we receive financial benefit for this, we will request your authorization before disclosing any PHI.
  • Release of Information to Family/Friends.  Rivergate Pediatrics may release your PHI to a friend or family member that is involved in your care.  For example, a parent or legal guardian may ask that a babysitter or a grandparent bring their child in for treatment.  In this example, the babysitter or grandparent may have access to the child’s medical information related to that visit.
  • Disclosures Required By Law.  Rivergate Pediatrics will use and disclose your PHI when we are required to do so by federal, state or local law.
  • Confidentiality for minors.  Rivergate Pediatrics will comply with state laws that allow minors to request treatment for certain conditions without parental consent or notification, and also with laws that allow 18 year olds to control access to their medical information. However, PHI may be disclosed to bill for services, (for example insurance companies or responsible parties).
  • Destruction of Records. Medical records (with the exception of immunization records) are destroyed 10 years after the patient becomes inactive or one year past majority (19 years of age) whichever is longer. The original records may be requested by you in lieu of destruction.
  • Other Uses and Disclosures. Uses and disclosures not described in this notice will be made only with a signed authorization from the patient/responsible party.


  • Public Health Risks.   Rivergate Pediatrics may disclose PHI about you for public health activities.  These activities may include the following: (1) maintaining vital records, such as births and deaths, (2) reporting child abuse or neglect, (3) to prevent or control disease, injury or disability, (4) to notify a person who may have been exposed to a disease or may be at risk for contacting or spreading a disease or conditions, (5) reporting reactions to drugs or problems with products or devices or if there has been a recall, (6) to notify the appropriate government authority if we believe a parent of one of our patients has been the victim of abuse, neglect or domestic violence (we will only disclose this information if the  patient or responsible party agrees or we are required by law), (7)  to notify your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.
  • Health Oversight Activities.  Rivergate Pediatrics may disclose your PHI to a health oversight agency for activities authorized by law.  These oversights may include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions, civil, administrative, and criminal procedures or actions.  These activities are necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
  • Lawsuits and Disputes.  Rivergate Pediatrics may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or dispute.  We may also disclose your PHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request.
  • Law Enforcement.  Rivergate Pediatrics may release PHI if asked to do so by a law enforcement official: (1) concerning a death that may have resulted  from criminal conduct, (2) regarding criminal conduct at our office, (3) in response to a warrant, summons, court order, subpoena or similar legal process, (4) to identify or locate a suspect, material witness, fugitive or missing person, (5) regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement, (6) in an emergency, to report a crime, the location of the crime or victim, or the description, identity or location of the perpetrator.
  • Deceased Patients.  Rivergate Pediatrics may release PHI to a medical examiner or coroner.  This may be necessary to identify the cause of death.  We also may release PHI to funeral directors to perform their jobs.  PHI of a deceased patient may be disclosed to family members who have been involved in treatment or payment, providing the disclosure is not contrary to any prior expressed preference of the individual that is known to Rivergate Pediatrics.  PHI is no longer protected by HIPAA laws 50 years after date of death.
  • Organ and Tissue Donation.  Rivergate Pediatrics may release PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transportation if you are an organ donor.
  • Research.  Rivergate Pediatrics may use and disclose your PHI for research purposes.  We will obtain your written authorization to use your PHI for research purposes except when research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.
  • Threat to Health and Safety.  Rivergate Pediatrics may disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public.  This information will be only disclosed to a person or organization able to help prevent the threat.
  • National Security.  Rivergate Pediatrics may disclose your PHI to federal officials for intelligence and national security activities authorized by law.  We may also disclose your PHI to federal officials in order to protect the President, other officials or foreign heads of state.
  • Military.  Rivergate Pediatrics may disclose your PHI if you are a member of U.S. or foreign military forces and if required by the appropriate authorities.
  • Inmates.  Rivergate Pediatrics may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official for your health and the health and safety of other individuals.
  • Worker’s Compensation.  Rivergate Pediatrics may disclose your PHI for worker’s compensation and other similar programs.
  • Sale of PHI or Use for Paid Marketing.  Rivergate Pediatrics will not sell our use your PHI for marketing purposes for which it receives financial benefit without your authorization.


  • Rights to Request Restrictions.  You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment, or health care operations.  You also have the right to request a limit to the PHI we disclose about you to certain family members or responsible parties involved in your care or payment for your care (for example, minors, when treated for STI’s, contraception, substance abuse, or behavioral/mental health). In addition, you may opt out of processes that allow your health care providers to share information about your PHI (for example, we may look up information about your prescription history when writing you a prescription). To request a restriction, please fill out our “Request for Limitation and Restriction of PHI” form and give it to Rivergate Pediatrics Administrator or your physician.  We are not required to agree to your request, but, if we do agree, we will make our best effort to comply, unless the information is needed to provide you emergency treatment or is otherwise required by law.  If you pay for services out-of-pocket, we must comply with your request to limit disclosures related to those services to insurance company or health plan.
  •  Rights to Confidential Communications.  You have the right to request that Rivergate Pediatrics communicates with you about your PHI in a particular manner i.e., contacting you at work instead of home.  In order to request this type of confidential communication you must request and fill out our “Request for Limitation and Restriction of PHI” form and give it to Rivergate Pediatrics Administrator or your physician. Rivergate Pediatrics will make its best effort to accommodate all reasonable requests.  You do not need to give a reason for your request.
  • Rights to Inspect and Copy.  You have the right to inspect and receive a copy of your PHI that Rivergate Pediatrics may use to make decisions about your treatment, including medical and billing records.  To request this information please fill out a “Request to Inspect and Copy PHI form” and give to Rivergate Pediatrics Administrator or your physician.  Rivergate Pediatrics may charge a fee for copying charges. Rivergate Pediatrics has a right to deny your request in certain circumstances; however, you may request a review of our denial by another licensed healthcare professional chosen by us.
  • Right to Amend.  You may request to amend your PHI if you believe Rivergate Pediatrics’ information about you is incorrect or incomplete.  This request can be made by completing a “Request to Amend Health Information form” and returning it to Rivergate Pediatrics Administrator or your physician.  We may deny your request if you ask us to amend information that is in our opinion: (1) accurate and complete, (2) not part of the PHI kept by or for Rivergate Pediatrics, (3) not part of the PHI you would be permitted to inspect and copy, for instance, psychotherapy notes, (4) not created by us, unless the person or entity that created the information is no longer available to make the amendment.  If the request is denied, you may file a statement of disagreement, and/or require the request and denial be attached to all future disclosures.
  • Right to Accounting of disclosures.  You have the right to receive an accounting of disclosure of your PHI, including a log of non-routine disclosures, and release of information for treatment, payment, or operations purposes.  Rivergate Pediatrics only releases information about your PHI for non-routine purposes when the patient has completed an “Authorization to Release “form.  An accounting of disclosures can be obtained by completing a ” Request an Accounting of Disclosures” form and giving it to Rivergate Pediatrics Administrator or your physician.  Within 30 days you will receive a report that tracts disclosures; this report may not include dates before April 14, 2003 or disclosures older than 6 years. Logs of disclosures made for purposes of treatment, payment and operations only go back 3 years. Multiple requests in a 12-month period will incur a fee.
  • Right to be notified of a Breach.  You will be notified within 60 days of the occurrence of unauthorized access or impermissible use of your PHI. The notice will contain, at a minimum, a description of the breach, a description of the types of information that were involved in the breach, the steps affected individuals should take to protect themselves from potential harm, a brief description of what Rivergate Pediatrics is doing to investigate the breach, mitigate the harm, and prevent further breaches, as well as contact information for Rivergate Pediatrics.   
  • Right to a Paper Copy of this Notice.  You have the right to receive a paper copy of Rivergate Pediatrics Notice of Privacy Practices at any time.  They will be available at the front desk. You may also see a copy at our website rivergatepediatrics.com.
  • Right to File a Complaint.  If you believe your privacy rights have been violated you may complete a “Patient Complaint form” and give it to Brenda Mayfield, or the current Privacy Officer of Rivergate Pediatrics.  Also, you may file a written complaint to the Roosevelt Freeman, Regional Manager, Office for Civil Rights, U.S. Department of Health and Human Services, Sam Nunn Atlanta Federal Center, Suite 16T70, 61 Forsyth Street, S.W., Atlanta, GA 30303-8909. You will not be penalized for filing a complaint.


Revised March 6, 2015