Privacy Policy

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Pediatric Associates of Dearborn provides every patient with a Notice of Privacy Practices that describes how their Protected Health Information (PHI) may be used and disclosed, the rights and responsibilities of patients with respect to their PHI, and the responsibilities of Pediatric Associates of Dearborn with respect to PHI it creates, collects, and maintains.


The Health Insurance Portability and Accountability Act of 1996 (HIPAA), requires each patient is provided with a Notice of Privacy Practices (NPP), to the health care organization’s patients. The goal of the NPP is to inform patients:

1. how the health care organization will use and disclosure a patient’s PHI;

2. the patient’s rights and responsibilities with respect to his/her PHI; and

3. the covered entity’s duties with respect to a patient’s PHI.

This Policy describes how Pediatric Associates of Dearborn NPP is provided to our patients and acknowledged, and who to contact with questions about the NPP.


  1. Each patient that receives health care services at Pediatric Associates of Dearborn will receive and will acknowledge receipt of the NPP.

    1. When a new patient arrives at their physician’s office:

      1. The individual responsible for the patient’s registration is responsible for providing the patient with the NPP and obtain a signed acknowledgement of receipt.
      2. The IDX system will document the receipt and acknowledgment that the patient received the NPP.
      3. A copy of the acknowledgement form should be kept in the patient’s medical record.
    2. If there is no documentation of a previous receipt and acknowledgment of the NPP, the health care provider’s office will:

      1. Provide the patient with the NPP;
      2. Request the patient to acknowledge receipt of the NPP by signing the Patient Acknowledgment form;
      3. If the patient refuses or is unable to sign the acknowledge their receipt of the NPP, the staff member shall document the patient’s refusal or inability to sign on the Patient Acknowledgment form along with any efforts that were made to obtain the patient’s acknowledgment on the form;
      4. File the Patient Acknowledgement form in the patient’s record; and,
      5. Record the receipt and acknowledgement in the IDX system.
    3. When patient’s file contains a signed Patient Acknowledgment form of registration, staff is not required to provide it to the patient.
  2. Requests for a NPP – If any individual requests a copy of the Pediatric Associates of Dearborn NPP, the person receiving the request should provide him/her with one in addition the NPP is posted on the Pediatric Associates of Dearborn website.
  3. Documentation – All documentation related to the receipt and acknowledgment of the NOPP will be maintained for a minimum of six (6) years.
  4. Questions – Questions the NPP or its contents should be directed to the HIPAA Privacy Officer. Questions about the distribution and acknowledgment process should be directed to the employee’s supervisor or the HIPAA Privacy Officer.
  5. Definitions – Protected Health Information, is information about a patient, including demographic information that may identify a patient, that relates to the patient’s past, present or future physical or mental health or condition, related health care services or payment for health care services.


  • Departments
  • HIPAA Privacy Officer

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