HIPAA Compliance

The Pediatric Associates HIPAA / Compliance page is a resource for patients, caregivers and employees and includes various Patient Forms and Patient Notices. The Patient Forms allow patients to request chart restrictions, copies of their medical records, request to have their medical record amended and request an accounting of medical record disclosures. The Patient Notices describe our Code of Conduct and explain the patient’s rights and our practice’s responsibilities regarding uses and disclosures of Protected Health Information in our Notice of Privacy Practices. Additionally, via our Corporate Compliance Hotline, patients may document positive customer service interactions with staff and medical care experiences with our providers; as well as let us know areas where we can improve our level of service to meet patients’ and caregivers’ expectations. Lastly, we are a culturally competent organization and we do not discriminate against patients or their caregivers who identify as having a language barrier or disability.

Download Patient Forms

pdf-icon Below are general forms available to download. To view the forms listed below, you will need Adobe Reader.

You can download Adobe Reader here.

  • HIPAA Form A – Request for Limitations and Restrictions of Protected Health Information
  • HIPAA Form B – Request to Release, Copy, or Inspect Protected Health Information
  • HIPAA Form C – Request for Correction/Amendment of Protected Health Information
  • HIPAA Form D – Request for an Accounting of Certain Disclosures of Protected Health Information for Non-TPO Purposes
  • HIPAA Form F – Patient Authorization for Practice to Release Protected Health Information to Third Parties

  • HIPAA Form A – Solicitud para Limitaciones y Restricciones de Informacion de Salud Protegida
  • HIPAA Form B – Solicitud de Liberacion, Copia, o Inspeccion de Informacion Medica Protegida
  • HIPAA Form C – Solicitud de Correccion/Enmienda de Informacion Medica Protegida
  • HIPAA Form D – Solicitud de Justificacion de Ciertas Divulgaciones de Informacion Medica Protegida para Propositos NO-TPO
  • HIPAA Form F – Autorizacion de Paciente para Liberacion de Informacion Medica Protegida a Terceros

Click here to read our Code of Conduct
Click here to read our Notice of Rights & Responsibilities

We are committed to ensuring that you are satisfied with the care and services you receive at our practice. Please let us know about your experience with us by calling our Global Compliance hotline at (866) 628-2385 or clicking on this link.