Policies & Forms

As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

This notice describes how health information about you, or your child, as the patient of this practice, may be used and disclosed and how you can get access to your individually identifiable health information. 

PLEASE REVIEW THIS NOTICE CAREFULLY. 

A. Our commitment to your privacy:
Our practice is dedicated to maintaining the privacy of your indivdually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:

• How we may use and disclose your PHI,
• Your privacy rights in your PHI,
• Our obligations concerning the use and disclosure of your PHI.

The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment of this ntoice will be effective for all your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will have a copy of our current Notice always posted in a visible location of the office, and you may request a copy of our most current Notice at any time.

B. If you have questions about this Notice, please contact:
NORWOOD PEDIATRICS
1136 Cleveland Ave, Ste 308
East Point, GA 30344

404-446-3900

C. We may use and disclose your PHI in the following ways:

1. Treatment. Our practice may use your PHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children, or parents. Finally, we may also disclose your PHI to other health care providers for purposes related to your treatment
2. Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts. 
3. Health care operations. Our practice may use and disclose your PHI to operate our business. For example, our practice may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your PHI to other health care providers and entities to assist in their health care operations
4. Appointment reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment. 
5. Treatment options. Our practice may use and disclose your PHI to inform you of potential treatment options or alternatives.
6. Health-related benefits and services. Our practice may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you. 
7. Release of information to family/friends. Our practice may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child to the pediatrician’s office for treatment of a cold. In this example, the babysitter may have access to this child’s medical information, with permission from the parent or legal guardian.
8. Disclosures required by law. Our practice will use and disclose your PHI when we are required to do so by federal, state, or local law.

D. Use and disclosure of your PHI in certain special circumstances:
The following categories describe unique scenarios in which we may use or disclose your identifiable health information:

1. Public health risks. Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of: 
2. Maintaining vital records, such as births and deaths,
3. Reporting child abuse or neglect,​
4. Preventing or controlling disease, injury, or disability,
5. Notifying a person regarding potential exposure to a communicable disease,
6. Notifying a person regarding a potential risk for spreading or contracting a disease or condition,
7. Reporting reactions to drugs or problems with products or devices, 
8. Notifying individuals if a product or device they may be using has been recalled,
9. Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information,
10. Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.  
11. Health oversight activities. Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure, and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
12. Lawsuits and similar proceedings. Our practice may use and disclose your PHI in response to a court or administrative order if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
13. Law enforcement. We may release PHI if asked to do so by a law enforcement official:
14. Regarding a crime victim in certain situations, if we are unable to obtain the person's agreement,
15. Concerning a death we believe has resulted from criminal conduct,
16. Regarding criminal conduct at our offices,
17. In response to a warrant, summons, court order, subpoena, or similar legal process,
18. To identify/locate a suspect, material witness, fugitive, or missing person,
19. In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity, or location of the perpetrator). 
20. Deceased patients. Our practice may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.
21. Organ and tissue donation. Our practice may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.
22. Serious threats to health or safety. Our practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
23. National security. Our practice may disclose your PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal and national security activities authorized by law. We also may disclose your PHI to federal officials in order to protect the president, other officials or foreign heads of state, or to conduct investigations.
24. Workers’ compensation. Our practice may release your PHI for workers’ compensation and similar programs. 

E. Your rights regarding your PHI:
You have the following rights regarding the PHI that we maintain about you:

1. Confidential communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must come to our office specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.
2. Requesting restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must come to our office . Your request must describe in a clear and concise fashion: 
3. The information you wish restricted,​
   Whether you are requesting to limit our practice's use, disclosure, or both,
   ​To whom you want the limits to apply.
4. Inspection and copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must come to our office in order to inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the costs of copying, mailing, labor, and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.
5. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, you must come to our office in order to inspect and/or obtain a copy of your PHI. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.
6. Accounting of disclosures. All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your PHI for purposes not related to treatment, payment, or operations. Use of your PHI as part of the routine patient care in our practice is not required to be documented – for example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must come to our office. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before October 1, 2022. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
7. Right to a paper copy of this notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, you must come to our office.
8. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, you must come to our office. All complaints must be submitted in writing. You will not be penalized for filing a complaint. 
9. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note: we are required to retain records of your care.



If you have any questions regarding this notice or our health information privacy policies, please contact our office through your child's patient portal or at 404-446-3900. 

Effective date: 10.14.2022   

Our goal is to provide and maintain a good medical provider-patient relationship. Letting you know in advance of our general office policies allows for a good flow of communication and enables us to achieve our goal. Please read each section carefully. If you have any questions, do not hesitate to ask a member of our staff. 

Masks

1. Following CDC guidelines, we recommend "that staff, patients, residents and visitors ... continue to wear masks as recommended in all healthcare facilities." If sick, every person over the age of 3 years is required to wear a mask. Masks must be placed over the nose and the mouth. If you do not follow these guidelines, you may be asked to reschedule your existing appointment and leave the office.

Electronics 

1. To optimize your time with your provider, kindly minimize the use of your electronics. Take the opportunity to engage with your child(ren) over books, coloring or in conversation.
2. Silence any devices when in the office. 

Appointments 

1. We value the time we have set aside to see and treat your child. If you are not able to keep an appointment, we require notice within 24 business hours. Failure to notify us in a timely manner will result in a $25 late cancellation or no show fee.
2. If you are late for your appointment (>15 minutes), we will do our best to accommodate you. However, it may be necessary to reschedule your appointment.  
3. We do not take walk-in appointments. You must schedule an appointment through your child's patient portal or by calling the office at 404-446-3900.
4. We strive to minimize any wait time; however, emergencies do occur and may take priority over a scheduled visit. We appreciate your understanding. 
5. Before making an annual physical appointment, check with your insurance company as to whether the visit will be covered as a healthy (well-child) visit.  

Insurance Plans  

1. Keep us updated with your correct insurance information. If the insurance company you designate is incorrect, you will be responsible for payment of the visit and to submit the charges to the correct plan for reimbursement. 
2. If we are your primary care physician (PCP), make sure our name or phone number appears on your card. If your insurance company has not yet been informed that we are your PCP, you may be financially responsible for your current visit. 
3. Make sure that you understand your benefit plan (covered services, participating laboratories, etc.). For example:
4. Not all plans cover annual healthy (well) physicals, sports physicals, or hearing and vision screenings. If these are not covered, you will be responsible for payment. 
5. For children younger than 2 years, there may be a limit as to the number of allowable well visits per year. If the number of visits is exceeded, your insurance company may not pay, in which case you will be responsible for payment. 
6. Know if a written referral or authorization is required to see specialists, whether preauthorization is required prior to a procedure, and what services are covered.  

Georgia Medicaid for Newborns

1. We require that proof of application be presented to our office within 5 business days. Proof of application can be documented by official acknowledgment in writing from the Department of Social Services stating that your application has been received. If you have an upcoming appointment, we ask that you provide a copy of the letter noting your appointment date; we will then need the proof of application within the 5 working days from the date of appointment. 
2. For accounting reasons, all medical charges will be listed as self-pay, but you will not be required to make payment on your account for the next 8 weeks. This is based on our understanding of the time it has been taking to receive a determination on your family’s application. If the Department of Social Services indicates that it will need additional time, we will need that in writing. 
3. If we have not received the Medicaid number of your child for billing by 8 weeks or have not received an extension letter from the Department of Social Services, you will be required to set up a payment plan for services rendered. Extensions can only be given if you provide written proof of a continuing application. 
4. It is YOUR responsibility to request that Medicaid go back to the date of your application to cover outstanding medical bills that your family may have incurred. We strongly suggest that you make that clear at the time of application because we can only bill Medicaid for services on or after the effective date of your coverage, once approved. Any medical charges incurred prior to the effective date of coverage will remain your responsibility. 
5. Our office cannot be responsible for speaking with social workers or for errors that may occur during your application process. This is a governmental process of benefit determination and approvals, between you and the Department of Social Services. 
6. Fulton County, as well as surrounding counties, has a mandatory enrollment in Medicaid managed care for children. Once you have been approved for Medicaid coverage, we suggest that you enroll your child with Medicaid, Ambetter, CareSource or PeachState when given your choice of a managed care plan. Please make sure you list E. Dorsey Norwood, MD as the primary care provider for your child. Otherwise, they might be assigned to a different managed care plan that we may not be participating in, and they may also be assigned to another primary care provider unknown to you. 

We are aware of how difficult and stressful this process can be for our families. Contact our billing department if you have additional questions or concerns, 404-446-3900.

Referrals  

1. Advance notice is needed for all non-emergent referrals (typically 3 to 5 business days). 
2. It is your responsibility to know if a selected specialist participates in your plan. 

Financial Responsibility  

1. According to your insurance plan, you are responsible for all co-payments, deductibles and coinsurances. 
2. Co-payments are due at the time of service. 
3. Self-pay patients are expected to pay for services in full at the time of the visit.  
4. If we do not participate in your insurance plan, payment in full is expected from you at the time of your visit. We will supply you with an invoice that you can submit to your insurance for reimbursement. 
5. Patient balances are billed immediately on receipt of your insurance plan’s explanation of benefits. Your remittance is due within 20 business days of your receipt of your bill.  
6. If previous arrangements have not been made with our finance office, any balance outstanding longer than 90 days will be forwarded to a collection agency. 
7. For scheduled appointments, prior balances must be paid, or payment plans established, prior to the appointment, or you may be asked to reschedule. 
8. If you participate with a high-deductible health plan, we require a copy of the health savings account debit or credit card, or a copy of a personal credit card to remain on file. 
9. We accept cash, checks, Visa, and MasterCard credit and debit. 
10. A $35 fee will be charged for any checks returned for insufficient funds; this is the fee that our bank, Pinnacle, charges us for returned checks. 

Forms

1. There is no charge for any paperwork related to the visit given at the time of your child’s visit. However, should you lose your forms, there may be a charge of $15 for each form that needs to be replaced. 
2. Any additional school, camp, or sports forms are subject to a $15-per-form fee.
3. Family and Medical Leave Act (FMLA) forms are $15. 
4. Forms will require 3-5 business days for completion. 

Transfer of Records  

1. If you transfer to another physician, we will provide a copy of your immunization record and your last visit to your physician, free of charge, as a courtesy to you. 
2. A copy of your complete record is available for a $30 fee. We provide records of your child for visits (includin consultations from specialists) rendered here at Norwood Pediatrics (or previously Lifcycle) only. For any previous records, you must request them directly fromyour previous doctor(s).
3. Record requests require 3-5 business days for completion. 

Prescription Refills  



1. We require 48 business hours notice for all prescription refills. Please plan accordingly. You may make medication requests through your child's patient portal or by calling the office at 404-446-3900.
    

Effective Date: 10.14.2022

Appointments may be requested through your child’s patient portal or by calling our office at 404-446-3900.

In the Office  

• Arrive early. Please remember that all insurance companies require that your insurance data be updated prior to each encounter. If this is not done, your insurance may deny your claim. We do not want time spent on administrative requirements to limit your time with the doctor.
• Schedule same-day appointments for ill visits. Appointments are used on a first-available appointment basis. You may schedule a same-day appointment by calling the office at 404-446-3900 or sending a request through your child's portal account.
• Patients who arrive on time are seen at their appointment time. Patients who have arrived on time will be seen ahead of those who arrive late. If you arrive late, we may need to abbreviate or reschedule your child's visit.
• Notify the office if you are late or unable to make your appointment time. You may reach us by calling the office at 404-446-3900 or sending a message through your child's portal account. We will do all taht we can to accommodate our child's appointment and to minimize the need to reschedule your appointment.
• Late arrivals (>15 minutes after scheduled appointment) will be offered the next available appointment. In these cases, a $25 no show charge for the lost appointment will apply. While we will do all that is possible to accommodate requests, the first available appointment may or may not be on the day the appointment was missed.
• Appointments canceled more than 24 business hours prior to when they were scheduled do not incur a no show or late cancellation fee.
• Appointments for additional children should be made prior to coming to the office. If you would like additional children to be seen, please schedule individual appointments for each child prior to coming to the office. If scheduled, we will accommodate two patients from the same family at the same time. If you have more than two children, additional appointments may need to be made on a different day.

Effective date: 12.01.2022   

• We firmly believe in the effectiveness of vaccines to prevent serious illness and to save lives.
   
• We firmly believe in the safety of our vaccines.
   
• We firmly believe that all children and young adults should receive all of the recommended vaccines according to the schedule published by the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP).
   
• We firmly believe, based on all available literature, evidence, and current studies, that vaccines do not cause autism or other developmental disabilities.
   
• We firmly believe that thimerosal, a preservative that has been in vaccines for decades and remains in some vaccines, does not cause autism or other developmental disabilities.
   
• We firmly believe that vaccinating children and young adults may be the single most important health promoting intervention we perform as health care providers, and that you can support as parents/caregivers.
   

The recommended vaccines and the schedule of administration are the results of years and years of scientific study and data-gathering on millions of children by thousands of our brightest scientists and physicians.

The vaccine campaign is truly a victim of its own success. It is precisely because vaccines are so effective at preventing illness that we are even discussing whether or not they should be given. Because of vaccines, many of you have never seen a child with polio, tetanus, whooping cough, bacterial meningitis, or even chickenpox, or known a friend or family member whose child died of one of these diseases. Such success can make us complacent or even lazy about vaccinating. But such an attitude, if it becomes widespread, can only lead to tragic results.

Over the past several years, many people in Europe have chosen not to vaccinate their children with the MMR (measles, mumps, rubella) vaccine after publication of an unfounded suspicion (later retracted) that the vaccine caused autism. As a result of under-immunization, there have been small outbreaks of measles and several deaths from complications of measles in Europe over the past several years. The United States experienced a record number of measles cases during 2019, with 1282 cases from 31 states reported to CDC's National Center for Immunization and Respiratory Diseases (NCIRD). This is the greatest number of cases since measles elimination was documented in the U.S. in 2000.

As medical professionals, we feel very strongly that vaccinating children on schedule with currently available vaccines is absolutely the right thing to do for all children and young adults. We are making you aware of these facts not to scare you or coerce you, but to emphasize the importance of vaccinating your child. We are more than willing to discuss any questions you may have about vaccines, but do require all new patients to our practice to adhere to the vaccination schedule endorsed by the American Academy of Pediatrics (AAP).

Effective date: 10.14.2022   

Please limit after-hour calls to urgent issues and emergencies. Before calling, we ask that you refer to the Resources tab on our website. You will find a Symptom Checker, the dosages of commone over-the-counter medications (Tylenol, Motrin, Benadril, etc.), as well as a medical library full of helpful information that may answer your questions.

For refills, appointment requests and other non-urgent matters, please send your requests through your child's patient portal or by calling the office at 404-446-3900.

If your matter is urgent, please consider the following when using this service:

• Speak slowly when engaging with the call service.
• Providers call through an app and do not know what number will appear on your phone. To make sure you do not miss the call, disable any call block features that may be enabled.
• Follow the provider's instructions. If you have further non-urgent questions after the call is completed, feel free to reach out through your child's patient portal or by calling the office at 404-446-3900.



Effective date: 10.14.2022  

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