Notice of HIPAA Privacy Policies

This notice describes how medical information about your child may be used and disclosed, and how you can get access to this information. These privacy policies are always available to review in our office, on our website and/or in your patient portal.

1. Our Commitment to Your Privacy: Dr. Cohen, Developmental Behavioral Pediatrician and CEO of Samantha Cohen, MD, Inc., is dedicated to maintaining the privacy of your child’s identifiable health information. We are required by law to provide you with this notice of our legal duties and privacy practices with respect to your child’s medical information.

2. Uses and Disclosures of Health Information: We use the health information that is gathered about your child to make diagnoses and/or to make recommendations for care that will help to optimize your child’s development and/or behavior. A secure electronic record of all correspondence and services your child receives in our office is kept for administrative, documentation and quality improvement purposes. The care and/or services your child receives from Dr. Cohen are confidential, except in the following circumstances:

• Threats of harm to self or others.

• Concerns about possible abuse of a child, vulnerable adult, or developmentally disabled person (Dr. Cohen is a mandated reporter).

• A court order to release information.

• Subpoena of treatment records by an attorney. If you do not want your information released, you must obtain a protective order from the court within fourteen (14) days of the subpoena issue date.

• If you are party to child custody litigation at any time in the future, the court may order the release of information about treatment in our office.

• If you will be utilizing your health insurance benefits by submitting a superbill, we may be required to provide information to your health plan, including some or all records of care/treatment that were provided for your carrier to provide you with reimbursement for our services. Your consent to the release of information to your health plan will be obtained prior to releasing it.

• In some instances, as provided by the state law of California, information about your healthcare may be exchanged with other healthcare professionals involved in your child’s treatment. In circumstances other than these, we will not release information about your treatment without your consent and authorization.

3. Your Health Information Rights: You and/or your child have the right to view and request copies of your child’s health information. You may ask that factual errors in the record be corrected. You may authorize in writing that copies of the record be released to entities you designate, at your expense, according to charges stipulated by state law of California. A $40.00 fee will be charged at your expense for a copy of the record. Under certain circumstances, where the record may put a patient or other person at risk, we may redact certain information in the record and/or require that you review the record in consultation with another health care provider. You and/or your child also have the right to request restrictions on certain uses and disclosures of your child’s health information.

4. Complaints: If you are concerned that we have violated your child’s privacy rights, or you disagree with a decision we made about access to your child’s records, you are encouraged to discuss them with Dr. Cohen. You may also send a written complaint to the U.S. Department of Health and Human Services.

5. Our Legal Duty: We are required by law to protect the privacy of your child’s information, provide this notice about our information practices, and follow the information practices that are described in this notice.

6. Changes to this Notice: We may change our policies at any time. Before any significant change in our policies, we will change our notice and post the new notice in our clinic and on our website.