Fair Lawn (201) 794-8585
Clifton (973) 249-1231
North Jersey Pediatrics

Notice of Privacy Policy

Effective April 14, 2003


This Notice tells you how we can collect, use and disclose your “protected health information” (PHI), and your rights concerning that information. It is issued in compliance with the provisions of the Federal Health Insurance Portability and Accountability Act. (HIPAA). PHI is information about you, including demographic information that can reasonably be used to identify you and which relates to your past, present or future physical or mental health condition, the provision of health care to you, and the payment for that care, as well as for our own operational purposes. We are required by law to provide you with this notice. We must adhere to the terms of this Notice while it is in effect. Some of the uses and disclosures mentioned in this notice may be limited by state laws which are more stringent that the Federal Law.

How we can use and disclose your PHI
  • We can use and disclose your PHI for purposes of treatment, payment and health care operations without your authorization. For example:
  • We use and disclose your PHI to other health care providers (doctors, dentists, hospitals, pharmacies, and others) to assist in your diagnosis, care and treatment.
  • We use and disclose your PHI to pay for your health expenses, such as to a billing company, or collection agency, and to process claims with your insurance company, or with other persons who may be responsible for payment.
  • We use and disclose your PHI in order to assist us with our own management and operation of our business activities, such as conducting quality and efficiency assessment, patient surveys, data management and customer services.

We can use and disclose your PHI in the following situations without your authorization:
  • We must disclose information whenever we are required to do so by law.
  • We may disclose information for the purpose of Public Health Activities, such as prevention of disease, injury or disability.
  • We may be required or may voluntarily report this information to government agencies in cases of Abuse, Neglect or Domestic Violence.
  • For Health Oversight Activities (for instance State insurance or health departments) as authorized by law.
  • In response to any Judicial or Administrative Order, such as a subpoena, court order, or discovery requests.
  • For Law Enforcement in limited circumstances such as in response to a warrant, to identify or locate a suspect, or to provide information about victims of crime.
  • To Coroners, Funeral Directors, and Organ Donation so their duties may be carried out safely and to preserve their purposes.
  • For Research, under circumstances where certain measures have been taken to protect your privacy.
  • For Special Government Functions involving intelligence and national security.
  • To comply with State workers’ compensation laws
  • To avert serious threat to health or safety to you or others.

Other Authorized uses or disclosures

We will make other uses and disclosures of your PHI only with your written authorization, unless otherwise permitted or required by law.

Some examples of this are in cases of emergency, when your authorization cannot be obtained due to the immediate circumstances. We will attempt to obtain your authorization in such case as soon as the emergency has passed. We may also use your information for marketing purposes, to others involved in your healthcare for directories, and with respect to psychotherapy notes, but again, only with your written authorization.

You may revoke your authorization in writing at any time, except to the extent that we have already taken action on the information disclosed or if we are permitted by law to use the information to contest a claim or coverage.

Your Rights regarding your PHI

You have a number of additional rights with regard to the PHI we maintain about you:
  • You have the right to obtain and review copies of your records, with some limited exceptions. Your request must be made in writing. We can and do charge a fee for the costs of producing, copying, and mailing you the requested information, but we will tell you about any cost in advance.
  • If you feel any of your PHI maintained by us is incorrect or incomplete, you can request the information be amended. This request must be written, and must state the reasons you feel a change is necessary.
  • We can deny your request if the information was not created by us or if it is already accurate or complete. If we deny your request, we will notify you in writing. You can then submit a written statement of disagreement, and we can make a rebuttal, all of which will be included in and be made a part of your records.
  • You have the right to request an accounting of the uses and disclosures we have made of your PHI. Any such accounting will not include uses and disclosures made for treatment, payment and health care operations, nor disclosures made with your authorization. It may also exclude disclosures made for national security purposes. Your request must be written and state the period of time for which you want an accounting. The time period may not be longer than for six years prior to the date of your request or for any period prior to 4/14/2003. Your request should indicate in what form you want the listing. Your first request in any 12 month period will be free. If you request additional listings, we can charge you an amount we tell you in advance.
  • You have the right to request restrictions on the use and disclosure by us of your PHI for treatment, payment and health care operations. We may not agree to your request. If we do agree, we will comply with your request except if it is needed in the case of an emergency. Your request must be in writing and state what information you want to limit; whether you want to limit the use, disclosure or both; and to whom the restrictions apply.
  • You have the right to request that we use a certain method to communicate with you about your health information or to send such communications to a certain location if the communication could endanger you. Your request must clearly state that all or part of the communication would endanger you.
  • You may specify where or how you want to be contacted. We will accommodate any reasonable request in this regard.
  • You have the right to request and receive a paper copy of this notice, even if you previously agreed to receive an electronic copy.
  • You can exercise any of the above rights by addressing your request to our Compliance Officer.

Changes to this Notice:

We reserve the right to and can change this Notice at any time, which can affect both past and future PHI we receive or create. We will notify you and provide you with a copy of the new notice and the effective date whenever a material change is made. A copy of our current notice is also posted in our office for your review.


If you believe your privacy rights have been violated, you may file a complaint with us and/or with the Secretary of the Department of Health and Human Services. All complaints must be made in writing and sent to our office at the address listed below. You will not be retaliated against for filing a complaint. We want to know so that we can take steps to prevent future occurrence.

Security of your Health Information:

We require our employees to follow all reasonable procedures to limit access to your PHI on a “need to know” basis to properly perform their job functions. Physical, technical and administrative policies and practices are established and followed to protect your privacy and ensure that your health information is secure to the greatest extent possible.

Contact Address:

Any questions, complaints, or requests concerned with this Notice should be addressed the attention of our HIPAA Compliance Officer at the address listed below:


Click here to download, complete and sign a Receipt of Privacy Policy Form.

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