Notice of Health Information Practices

  • This notice is included in each family handbook to describe how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully and acknowledge receipt by signing the enclosed form.


    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, diagnoses, treatment, and a plan for future care or treatment. This information, which we refer to as your health or medical record, is an essential part of the health care we provide for you. It serves as a:
    • Basis for planning your care and treatment
    • Means of communication among the many health professionals who contribute to your care
    • Legal document describing the care you receive
    • Means by which you or a third-party payer can verify that services billed were actually provided
    • Tool for educating health professionals
    • Source of data for medical research
    • Source of information for public health officials charged with improving the health of the nation
    • Source of data for facility planning and marketing
    • Tool with which we can assess and continually work to improve the care we render and the outcomes we achieve

    Your health record contains personal health information, the confidentiality of which is protected under both state and federal law. Understanding we expect to use and disclose your health information helps to:
    • Ensure its accuracy
    • Better understand who, what, when, where, and why your health care providers and others may access your health information
    • Make more informed decisions when authorizing disclosure to others


    Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. Under the Federal Privacy Rules, 45 CFR Part 164, you have the right to:
    • Receive notice of the uses and disclosures we expect to make of your health information, including a paper copy of the notice if requested, as provided in Rule 520.
    • Request additional restrictions on uses and disclosures of your health information (though we are not required to agree to any such request), or request that we send you confidential communications by alternative means or at alternative locations, as provided in 45 CFR 164.522.
    • Inspect and obtain a copy of your health record as provided in 45 CFR 164.526.
    • Obtain an accounting of disclosures of your health information made after April 14, 2003, for purposes other than treatment, payment or health care operations, as provided in 45 CFR 164.528.


    We are required by the Federal Privacy Rules to:
    • Maintain the privacy of your health information
    • Provide you with a notice as to our legal duties and privacy practices with respect to health information we collect and maintain about you.
    • Abide by the terms of this notice, subject to the following reservation of rights.
    We reserve the right to change our health information practices and the terms of this notice, and to make the new provisions effective for all protected health information we maintain, including health information created or received prior to the effective date of any such revised notice. Should our health information practices change, we will post and/or provide a revised notice. We will not use or disclose your health information without your consent or authorization, except as described in this notice.


    For example: Information obtained by a nurse, physician, or other member of the office of EBS Early Intervention will be recorded in your medical record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment.

    We will also provide your primary care physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you. We may also send relevant portions of your medical record to specialists to whom you are being referred for care, or to physicians whom your providers here may want to consult on a care issue.

    We may use and disclose health information about you (for example, by calling you or sending you a letter or card) to remind you that you have an appointment with us for treatment or that it's time for you to schedule a regular checkup with us, or to provide you with information about treatment alternatives.


    For example: A bill may be sent to you or your insurance company or health plan. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.


    For example: Members of the office of EBS Early Intervention or members of a quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the service we provide.


    We provide some services with business associates, who are independent professionals that use patient health information provided by us in order to perform these services. Examples include a billing service and an answering service. When these services are contracted, we may disclose your health information to our business associate so that that they can perform the job we have asked them to do and bill you or your insurer for services rendered. To protect your health information, we require the business associate to appropriately safeguard your information.


    Family or friends involved in care: Unless you object in writing, health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or payment related to your care.

    Marketing and fundraising: We may use or disclose your health information in connection with limited marking or fundraising communications permitted under the Federal Privacy Rules. Any such communication addressed to you will contain instructions describing how you may "opt out" of receiving further such communications.


    The Federal Privacy Rules requires us to disclose your personal health information in two instances:
    • To you at your request under 45 CFR 164.524 or 45 CFR 164.528 and
    • To the Secretary of Health and Human Services when requested as part of an investigation or compliance review under 45 CFR 164.502.


    In addition, 45 CFR 164.512 permits uses and disclosure of your health information without your consent or authorization for certain "national priority" purposes, including:
    • When required by state or federal law
    • To state and federal public health authorities, including state medical officers, the Food and Drug Administration (FDA), and other agencies charged with preventing or controlling disease.
    • To government authorities, including protective service agencies, authorized to receive reports of abuse, neglect, or domestic violence.
    • To government health oversight agencies, such as the state and federal Departments of Health and Human Services, Medicare/Medicaid Peer Review Organizations (PRO's), state Boards of Medicine, Nursing, and Pharmacy, and other licensing authorities.
    • When required by court order in a judicial or administrative proceeding.
    • To law enforcement officials for certain law enforcement purposes, including the reporting of certain types of wounds or injuries, or pursuant to a warrant, subpoena, or other legal process, or for the purpose of identifying or locating a subject, fugitive, material witness, missing person, or victim, provided that the conditions in the rule are met.
    • To coroners, medical examiners, or funeral directors for purposes of identifying a deceased person or carrying out their duties as required by law.
    • To organ procurement organizations for purposes of organ or tissue donation and transplantation, consistent with applicable law.
    • For research approved by an Institutional Review Board (IRB) or Privacy Board that has reviewed the research protocol and established protocols to ensure the privacy of your health information.
    • When required to avert a serious threat to health or safety.
    • When requested for certain specialized government functions authorized by law, including military and similar situations.
    • As authorized by law in connection with workers compensation programs.


    We expect to make other uses and disclosures of your protected health information only on the basis of specific written authorization forms signed by you. You have the right to revoke any such authorization at any time, except to the extent we have already relied on it in making an authorized use or disclosure.


    If you have any questions you may contact our headquarters:

    EBS Early Intervention
    200 Skiles Boulevard
    West Chester, PA 19382
    Phone: 800-578-7906

    If you believe your privacy rights have been violated, you can file a complaint with:

    The Secretary of Health and Human Services
    Department of Health and Human Services
    Office of the Secretary
    200 Independence Avenue S.W.
    Washington, D.C. 20201
    Phone: 202-690-7000

  • EBS Early Intervention will use and disclose your personal health information to provide treatment, to receive payment for the care we provide, and for other health care operations, including activities we perform to improve the quality of care.

    We have prepared a detailed Notice of Privacy Practice to help you better understand our policies in regards to your personal health information. The terms of the notice may change with time and we will provide you with copies of these changes.

    EBS can leave voicemails containing your/your child’s medical information on the phone number(s) listed below. This information may include, but is not limited to, demographic information (patient name, date of birth, addresses, etc.), billing information, and medical information (appointment dates, changes in session plans, etc.).

    I, the undersigned, consent to voicemails containing my child’s medical information at the following phone number(s):

  • For questions, comments or to report a problem, contact EBS Early Intervention at 800-578-7906.

    By my signature below, I certify that I have read and understood the items on this form and I acknowledge that I have received a copy of the Notice of Privacy Practice. I have given truthful information about my/my child’s identity, and that I am either the patient or the patient’s legally authorized representative.
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