Privacy Policy
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.
OUR RESPONSIBILITY
Thrive Pediatrics, LLC (“the Practice” or “We”) is committed to protecting the privacy of your medical
information. Your care/treatment is recorded in a medical record that is considered protected health
information (“PHI”). To best meet your medical needs, We share your PHI with the providers and
facilities involved in your care. We share your information only to the extent necessary to collect
payment for services We provide and to conduct our business operations. Practice staff is trained to
be sensitive to the privacy and confidentiality of your PHI. Except as outlined below, We will not use
or disclose your PHI for any other purpose unless you have signed a Medical Record Release
Authorization form.
USES AND DISCLOSURE OF YOUR PHI
We may use and share your PHI in the following ways without requiring your authorization. It should
be noted that while not every use or disclosure will be listed, each of the ways we are permitted to
use or disclose information will fall into one of the following areas:
● To provide, coordinate or manage your medical treatment and services. For instance,
providers involved in your care, will use information in your medical record to plan a course
of treatment for you that may include procedure, medications, tests, etc. We may also
disclose your PHI to institutions and individuals outside of the Practice that are or will be
providing treatment to you.
● To bill and receive payment for the treatment and services you received. For instance, we
may forward information regarding your medical procedures and treatment to your employer
to arrange payment for the services provided to you or we may use your information to
prepare a bill to send to you or to the person responsible for your payment.
● To run our practice, improve your care, and contact you when necessary. For example, we
may use your PHI in order to conduct an evaluation of treatment and services we provide.
● We may use your PHI to remind you about appointments and from time to time, to
communicate with you about treatment alternatives and other health-related benefits and
service that may be of interest to you.
● For workers’ compensation or similar programs.
● For public health safety issues such as preventing disease, helping with product recall,
reporting adverse reactions to medications, reporting suspected abuse, neglect, or domestic
violence.
● For a health oversight agency.
● In response to a court order, subpoena, or warrant and to law enforcement officials in certain
limited circumstances.
RIGHTS THAT YOU HAVE
When it comes to your health information, you have certain rights. This section explains your rights
and some of our responsibilities to help you.
● You can ask to see or get an electronic or paper copy of your medical record, by filling out a
Medical Record Authorization form and submitting it to our office. We will provide a copy of
your medical record within 30 days of your request.
● You can ask us to correct your medical record if you think it is incorrect or incomplete. You
will need to complete a Health Information Amendment form and submit it to our office. We
may decline your request, but we’ll tell you why in writing within 60 days.
● You can ask us not to share certain medical record information for treatment or payment.
● You can ask us to communicate with you by email or standard SMS messaging
● You can ask us to contact you in a certain way or at a certain location.
● You can ask for an accounting of the times we have shared your medical record for the last 6
years, who we shared it with and why.
● You can ask for a paper copy of this notice at any time.
● You can choose someone to whom information may be disclosed or if someone is your legal
guardian, that person can make choices about your medical record.
BREACH NOTIFICATION
We are required to notify you in writing of any breach of your unsecured PHI as soon as possible,
but in any event, no later than 60 days after we discovered the breach.
At times it may be necessary for us to provide your PHI to one or more outside persons or
organizations who assist us with our payment/billing activities and healthcare operations. In each
case, we require these business associates and any of their subcontractors, to appropriately
safeguard the privacy of your information.
OUR NOTICE OF PRIVACY PRACTICE
We are required by law to maintain the privacy of our patients’ PHI. We are required to abide by the
terms of this Notice of Privacy Practice so long as it remains in effect. We reserve the right to change
the terms of this Notice of Privacy Practice as necessary. You may receive a copy of any revised
notice at any of our clinic locations.
This Notice of Privacy Practice is effective January 1, 2025.
COMPLAINTS
If you have any questions about this Notice or if you think that we have not respected the privacy of
your protected health information, please do not hesitate to contact Practice by email at the following email address: drkurowski@thrivepedswi.com.
Your signature below is an acknowledgement that you have been provided with a copy of this Notice.
_____________________________________________
Patient Name
_____________________________________________ ____________
Signature of Patient or Parent or Legal Guardian Date
_____________________________________________
Name of Parent or Legal Guardian (if applicable)
Rev January 1, 2025