Privacy Practices

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.

Who We Are

The Seacoast Child Development Clinic is a clinical component of Dartmouth Hitchcock Medical Center in partnership with the Institute on Disability at the University of New Hampshire. Professionals and faculty from both UNH and Dartmouth Hitchcock Medical Center staff the clinic, and trainees are part of the interdisciplinary team. This Notice of Privacy Practices applies only to the operations and care provided by the Seacoast Child Development Clinic, and does not apply to services provided by other University of New Hampshire departments or by Dartmouth-Hitchcock entities.

Our Privacy Obligations

The law requires us to maintain the privacy of certain health information called “Protected Health Information” (“PHI”). PHI is the information that you provide us and the information that we create, receive or maintain about your health care. The law also requires us to provide you with this Notice of our legal duties and privacy practices. When we use or disclose (share) your PHI, we are required to follow the terms of this Notice or other notice in effect at the time we use or share the PHI. In the event of a breach of unsecured PHI, we are also required to notify you if you are affected by such a breach. Finally, the law provides you with certain rights described in this Notice.

Ways We Can Use and Share Your PHI Without Authorization

In many situations, we can use and disclose your PHI for activities that are common in clinics. In certain other situations, which we will describe below, we must have your written permission (authorization) to use and/or disclose your PHI. We do not need authorization from you for the following uses and disclosures:

Treatment, Payment, and Healthcare Operations
  • Treatment: We use and share your PHI to provide care and other services to you – for example, to assess your child’s development. In addition, we may contact you to provide appointment reminders or information about clinic services. We may tell you about other health related benefits and services we provide that might interest you. We may also share your PHI with other doctors, nurses, and others involved in your care.
  • Payment: We may use and share your PHI to receive payment for services that we provide to you. For example, we may share your PHI request payment, and collect payment from you, NH Medicaid, or a third party or other program that arranges or pays the cost of some or all of your health care (“Your Payor”) and to confirm that Your Payor will pay for the health care.
  • Health Care Operations: We may use and share your PHI for our health care operations, which include management, planning, and activities that help to improve the quality and efficiency of the care that we deliver. For example, we may use PHI to review the quality and skill of our physicians, trainees, and other health care providers or for their training. In addition, we may share PHI with certain others who help us with our activities, including those we hire to perform services.
Your Healthcare Providers Outside of the Seacoast Child Development Clinic

We may also share some portion of your PHI with your doctor and other health care providers when they need it to provide Treatment to you, to obtain Payment for the care they give to you, or to perform certain parts of their Health Care Operations, such as reviewing the quality and skill of their health care professionals.

Health Information Exchange

If your care at the Seacoast Child Development Clinic is provided by a practitioner affiliated with a hospital in New Hampshire (for example, Dr. Moeschler is a provider at the Children’s Hospital at Dartmouth-Hitchcock), we may transmit PHI through a health information exchange to other health care providers involved in your care. The New Hampshire Health Information Organization (NHHIO) is a New Hampshire non-profit organization that has been authorized to operate a New Hampshire statewide electronic health information network to share patient health information between health care providers in a timely, secure, and confidential manner. You may request that we not share your name and address or PHI with NHHIO or use NHHIO as one of the methods by which we electronically transmit your PHI. In order to do this, you must submit your request in writing to the Seacoast Child Development Clinic.

Disclosure to Relatives, Close Friends and Your Other Caregivers

We may share your PHI with your family member/relative, a close personal friend, or another person who you identify if we (1) first provide you with the chance to object to the disclosure and you do not object; (2) infer that you do not object to the disclosure; or (3) obtain your agreement to share your PHI with these individuals. If you are not present at the time we share your PHI, or you are not able to agree or disagree to our sharing your PHI because you are not capable or there is an emergency circumstance, we may use our professional judgment to decide that sharing the PHI is in your best interest.

Public Health and Safety Activities

We are required or are permitted by law to report PHI to certain government agencies and others. For example, we may share your PHI for the following:

  • To report health information to public health authorities for the purpose of preventing or controlling disease, injury, or disability;
  • To report abuse or neglect to the appropriate State agencies;
  • To prevent or lessen a serious and imminent health or safety threat to you, another person, or the public;
  • To authorized federal officials for national security activities or specialized government functions.
Health Oversight Activities

To the extent authorized by law, we may share your PHI with a health oversight agency that oversees the health care system and ensures the rules of government health programs, such as Medicaid, are being followed.

Legal and Administrative Proceedings

We may share your PHI in the course of a legal or administrative proceeding as required by law or in response to a court order.

Law Enforcement Purposes

We may share your PHI with the police or other law enforcement officials as required or permitted by law or in compliance with a court order.

  • After a client’s death, we may also share limited information with friends or family who have been involved in providing or paying for that client’s care, unless doing so is inconsistent with any prior expressed preference that client made known to us.
  • We are required to comply with the privacy protections for the PHI of a deceased individual for a period of fifty (50) years following the death of the individual.



We may use or share your PHI for research without your authorization in certain circumstances, subject to certain safeguards. For example, we may disclose information to researchers when their research has been approved by a special committee (the Institutional Review Board) that has reviewed the research proposal and established protocols to ensure the privacy of your health information, or for certain reviews in preparation for setting up a research protocol.

As Required by Law

We may use and share your PHI to the extent we are required to do so by any other law not already referred to above.

Written Permission For Other Uses and Disclosures of Your PHI

Use or Disclosure with Your Permission (Authorization)

For purposes other than the types described above, we may only use or share your PHI when you grant us your written permission (authorization).

Certain Health Information

In most cases, we will not be able to disclose the following types of health information without your written authorization:

  • HIV testing and test results
  • Genetic testing and test results
  • Drug and alcohol abuse treatment records
  • Confidential communications between you and a sexual assault or domestic violence counselor
  • Confidential communications between you and a mental health practitioner (psychiatrists, psychiatric nurse practitioners, psychotherapists, clinical social workers, clinical mental health counselors, marriage and family therapists)

We must obtain your written authorization prior to using your PHI for marketing. However, we may use your PHI to communicate with you about certain treatment and health care operations purposes, which are not considered marketing, including communications about: products or services we offer, case management, care coordination, or other communications about alternative treatments, therapies, health care providers, or care settings.

Psychotherapy Notes

Except in very limited circumstances as permitted by law, we will not use or disclose psychotherapy notes without your written authorization. Psychotherapy notes are those created for the therapist’s own use and maintained separate from the medical record. However, specific permission is not required for use or sharing of these notes if used by your therapist to treat you, for training programs, for legal defense in an action you bring, or for professional oversight of the therapist.

Your Rights Regarding Your Protected Health Information

Right to Receive Confidential Communications

You may ask us to communicate with you in certain ways (such as by letter or by phone), or at a certain location (for example, only at home). You will need to ask us in writing. We will try to grant your request if we feel it is reasonable.

Right to Revoke Your Authorization

You may change your mind about your authorization to disclose your PHI by sending a written “revocation statement” to the Seacoast Child Development Clinic at the number below. The revocation will not apply to the extent that we have already taken action based on your authorization.

Right to Access your PHI

You may request access to your medical record file, billing records, and other records used to make decisions about your treatment and payment for your treatment. You can review these records and/or ask for copies. Under limited circumstances, we may deny you access to a portion of your records (e.g., psychotherapist’s notes) if your provider feels that providing access could cause harm to you or someone else. We will respond to your request for records no later than 30 days after your request is received.

If you want to access your records, you may obtain an authorization form from the Seacoast Child Development Clinic. If you request copies of your records, we may charge you the amount it costs us per page to make the copies. We may also charge you for our postage costs. For a copy of records, material, or information that cannot routinely be copied on a standard photocopy machine, such as videos, we may charge for the reasonable cost of the copy.

You have the right to request copies of your records in electronic format. If you wish, we can provide electronic copies of records we keep electronically on media we provide. Our standard charges will apply.

Right to Amend Your Records

You have the right to request that we amend your PHI maintained in medical record files, billing records, and other records used to make decisions about your treatment and payment for your treatment. Once we have received your written request, we will comply with your request unless we believe that the information that would be amended is correct and complete or that other circumstances apply.

Right to Receive an Accounting of Disclosures

You have the right to request an “accounting of disclosures” of your PHI made for reasons other than treatment, payment, or health care operations, or with your authorization. You must make this request in writing to the Seacoast Child Development Clinic. The request cannot cover dates after the date on the request, or for more than a six (6) year period. We may charge you for the costs of providing the information.

Right to Request Restrictions

You have the right to ask us to restrict or limit the PHI we use or disclose about you for treatment, payment, or health care operations. However, we are not required to agree to your request (other than a request to restrict a disclosure to a health plan under the circumstances described below) and we will not agree to any request unless we feel that we can fully live up to our promise to do so.

We will agree, upon your written request, to a request to restrict disclosure of PHI about you to a health plan if: (1) the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and (2) the PHI pertains solely to a health care item or service for which you, or a person (other than the health plan) on behalf of you, has paid the Seacoast Child Development Clinic in full.

For Further Information

All requests to exercise your rights described in this Notice must be in writing. If you wish to obtain request forms, or want additional information about how to exercise any of your rights described in this section, please contact the Seacoast Child Development Clinic.

If you want more information about your privacy rights, are concerned that we have violated your privacy rights, or disagree with a decision that we made about access to your PHI, you may contact the Seacoast Child Development Clinic. You may also file a written complaint with the Office for Civil Rights (OCR) of the U.S. Department of Health and Human Services. When you ask, the Seacoast Child Development Clinic will provide you with the correct address for the OCR. We will not take any action against you if you file a complaint with us or with the OCR.

Change in Terms of this Notice

We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in a common area at the Seacoast Child Development Clinic. You also may obtain a copy of this notice, including a paper copy, by contacting the Seacoast Child Development Clinic.

Seacoast Clinic
Betsy Humphreys
55 College Road, 103 Pettee Hall
Durham, NH 03824
P: (603) 862-0561
F: (603) 862-0034

This Notice is effective as of January 5, 2014

You may download the full-text PDF of this document here.

Please note that Adobe Acrobat will be required to view the document. You may download that here.

Alternative formats are available, please contact the Clinic if you need assistance.