Notice Of Privacy Practices

Notice Of Privacy Practices

Charity Jackson, MD
Kerri M. Bagnall, MD
M. Elisa Valdez, MD
Erica P. Mulder, MD
Pamela A. Limb, MD
Sean Bradley, MD


Effective Date: January 01, 2015


If you have any questions about this notice, please contact the Privacy Official by dialing (719) 633-3850

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnosis, treatment, a plan for future care or treatment, and billing-related information. This notice applies to all of the records of your care generated by the practice, whether made by practice personnel, agents of the practice, or your personal doctor.


We are required by law to maintain the privacy of your child’s health information and provide you a description of our privacy practices. We will abide by the terms of this notice and notify you if we cannot agree to a requested restriction. We will accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.


How we may use and disclose Medical information about your child.

The following categories describe examples of the way we use and disclose medical information:

For Treatment

We may use medical information about your child to provide treatment or services. We may disclose medical information about your child to nurses, technicians, medical students, other physicians, and/or hospital personnel who are involved in your child’s care. For example: a specialist treating your child for a broken leg may need to know if your child has diabetes because diabetes may slow the healing process.

We may also provide other healthcare providers with copies of various reports that should assist him/her in treating your child.

For Payment

We may use and disclose medical information about your child’s treatment and services to bill and collect payment from you, your insurance company or a third party payer. For example, we may need to give your insurance company information about your child’s care so they will pay us or reimburse you for the treatment. We may also tell your health plan about treatment your child is going to receive to determine whether your plan will cover it.

For Health Care Operations

Members of the staff may use information in your health record to assess the care and outcomes in your case and others like it. The results will then be used to continually improve the quality of care for all patients we serve. For example, we may combine medical information about many patients to evaluate the need for new services or treatment. We may disclose information to doctors, nurses, and other medical professionals for educational purposes.

We may also use and disclose medical information:

  • To business associates we have contracted with to perform the agreed upon service and billing for it:
  • To remind you that you have an appointment for medical care:
  • To assess your satisfaction with our services
  • To tell you about possible treatment alternatives
  • To tell you about health-related benefits or services
  • For Population based activities relating to improving health or reducing health care costs: and
  • For conducting training programs or reviewing competence of health care professionals.

Business Associates

There are some services provided in our organization through contracts with business associates. Examples include services for radiology, laboratory testing, and transcription services. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

Individuals Involved in Your Child’s Care or Payment for Your Child’s Care

We may release medical information about your child to a friend or family member who is involved in his/her medical care or who helps pay for his/her care. In addition, we may disclose medical information about your child to an entity assisting in a disaster relief effort so that your family can be notified about your child’s condition, status and location.

Future Communications

We may communicate to you via newsletters, mail outs or other means regarding treatment options, health related information, disease-management programs, wellness programs, or other community based initiatives or activities our practice is participating in.

Organized Health Care Arrangement

This practice is presenting you this document as a notice. Information will be shared as necessary to carry out treatment, payment and health care operations. Physicians and caregivers may have access to protected health information in their offices to assist in reviewing past treatment as it may affect treatment at the time.

Affiliated Covered Entity

Caregivers at other facilities or practices may have access to protected health information at their locations to assist in reviewing past treatment information as it may affect treatment at this time. Please contact the facility or practice Privacy Official for further information on the specific sited included in this affiliated covered entity.

As Required by Law

We may also use and disclose health information for the following types of entities, including but not limited to:

  • Food and Drug Administration
  • Public Health or Legal Authorities charged with preventing or controlling disease, injury or disability
  • Correctional Institutions
  • Workers Compensation Agents
  • Organ and Tissue Donation Organizations
  • Military Command Authorities
  • Health Oversight Agencies
  • National Security and Intelligence Agencies
  • Protective Services for the President and Others

Law Enforcement/Legal Proceedings

We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

State Specific Requirements

Many states have requirements for reporting including population-based activities relating to improving health or reducing health care costs.

Your Health Information Rights

Although your health record is the physical property of the practice practitioner or facility that complied it, you have the Right to:

Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your child’s care. Usually, this is medical and billing records, but does not include psychotherapy notes or other notes, which we are legally forbidden to disclose. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another healthcare professional chosen by the practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Amend: If you feel that medical information we have about your child is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the practice.

We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial.

An Accounting of Disclosures: You have the right to request an accounting of disclosures. This is a list of the disclosures we make of medical information about your child.

Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about your child for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about your child to someone who is involved in his/her care or the payment for his/her care, like a family member or friend. For example, you could ask that we not use or disclose information about a visit that your child had.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide your child with emergency treatment.

Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. We will agree to the request to the extent that it is reasonable for us to do so. For example, you can ask that we use an alternative address for billing purposes.

A Paper Copy of this Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To exercise any of your right, please obtain the required forms for the Privacy Official and submit your request in writing.

Changes to this Notice

We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted in the office and include the effective date. In addition, each time you and/or your child visit the practice for treatment or health care services, we will have available a copy of the current notice in effect.


If you believe your privacy rights have been violated, you may file a complaint with the practice by contacting the main number and asking for the practice Privacy Official or with the Secretary of the Department of Health and Human Services. To file a complaint with the practice, contact the Privacy Official. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

Other Uses of Medical Information

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about your child, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about your child for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to your child.

Privacy Officials

Kerri M. Bagnall, MD
Erica P. Mulder, MD
M. Elisa Valdez, MD

(719) 633-3850

402 N. Tejon Street Suite 200
Colorado Springs, CO 80903