Forms And Policies

Resources and Information


For your convenience, we have posted a number of commonly used forms that you may be asked to complete when you visit one of our offices. These forms are available in PDF format, and are available for you to download, print and complete prior to your visit. By completing forms ahead of time, you can minimize the amount of time you spend at our office.

Privacy Policy Notice:


Who will get this notice?

PGV Pediatrics, P.A. provides health care to our patients in partnership with physicians and other professionals and organizations. The information privacy practices in this notice will be followed by:

  • Any health care professional who treats you, or your child in any of our locations.
  • All employed staff, resident physicians, medical or nursing students gaining work experience at PGV Pediatrics P.A.
  • Any business associate or partner with whom we share health information.

Our pledge to you

We understand that medical information about you and your child is personal and we are committed to protecting this information. We create a record of the care and services you receive to provide quality care and to comply with legal requirements. This notice applies to all of the records of your child’s care that we maintain, whether created by office staff, medical staff or your physician or nurse practitioner. Specific policies may apply to particular clinical procedures or diagnoses. In order to provide optimal care for you or your child, medical records are sometimes transferred between our offices by an employee. We are required by law to:

  • Keep medical information about you, or your child, private.
  • Give you this notice of our legal duties and privacy practices with respect to medical information about you or your child.
  • Follow the terms of the notice that is currently in effect.

Changes to this notice

We may change our policies at any time. Changes will apply to medical information we already hold as well as new information after the change occurs. Before we make a significant change in our policies, we will change our notice and post the notice in waiting areas, exam rooms, and through other means as they may exist at the time. You can receive a current copy of the notice at any time. The effective date is listed at the end of this notice.

How we may use and disclose medical information about you or your child.

  • We may use and disclose medical information about you or your child for treatment (such as sending information about your child to a laboratory to order a test); to obtain payment for treatment (such as sending billing information to your insurance company); and to support our health care operation (such as comparing patient data to improve treatment methods).
  • We may use or disclose medical information about you or your child, without your prior authorization for several other reasons. Subject to certain requirements, we may give out medical information about you or your child without prior authorization for public health purposes, health oversight audits or inspections, research studies, funeral arrangements, organ donation, workers’ compensation and emergencies. We also disclose medical information when required by law, or in response to valid judicial or administrative orders, such as a court order or subpoena.
  • We may also contact you for appointment reminders, or to tell you about treatment options, alternatives, health related benefits or services that may be of benefit or interest to you. If you do not want automated reminder notices by phone, you must indicate this choice to us in writing.
  • We may disclose medical information about you or your child to a friend or family member who is involved in your medical care (such as a babysitter who brings your child for treatment.)

Other uses of medical information

In any other situation not covered by this notice, we will ask for your written authorization before using or disclosing medical information about you or your child. If you choose to authorize use or disclosure, you may later revoke that authorization by notifying us in writing of your decision.

Your rights regarding medical information about you or your child In most cases you have a right to look at or get a copy of medical information that we use to make decisions about your or your child’s care, when you make a written request. If you request copies, we may charge a fee for the cost of copying, mailing, or other related supplies. If we deny your request, you may submit a written request for a review of that decision.

If you believe that information in your child’s record is incorrect or if important information is missing, you have the right to request that we correct the records by submitting a request in writing that provides your reason for requesting the amendment. We could deny your request to amend the record if the information was not created by us; if it is not part of the medical information maintained by us; or if we determine that the record is accurate. You may appeal, in writing, a decision by us not to amend a record.

You have the right to a list of those instances where we have disclosed medical information about you or your child, other than for treatment, payment, healthcare operations or where you specifically authorized a disclosure, when you submit a written request. The request must state the time period desired for the accounting, which must be less than a 6-year period and starting after April 14th 2003. You may receive the list in paper or electronic form. The first disclosure list in a 12-month period is free; other requests will be charged according to our cost of producing the list. We will inform you of the cost before you incur any costs.

If you receive this notice electronically, you have the right to a paper copy of this notice.

You have the right to request that medical information about you or your child be communicated to you in a confidential manner, such as sending mail to an address other than your home address, by notifying us in writing of the specific way or location for us to use to communicate with you.

You may request, in writing, that we do not use or disclose medical information about you or your child for treatment, payment or healthcare operations or to persons involved in your care except when specifically authorized by you, when required by law, or in an emergency. We will consider your request but we are not legally required to accept it. We will inform you of our decision on your request. All written requests should be submitted to: 3417 Gaston Ave #845, Dallas, TX 75246


If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you may contact our Privacy Officer as listed above.

Finally you may send a written complaint to the U.S. Department of Health and Human Services. Our Privacy Officer can provide you with the address.

Under no circumstances will you be penalized or retaliated against for filing a complaint.

Effective date
March 11, 2015
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