1. Warm words about why the policies and when to do it and how important they are to smooth operation, etc.
      1. [write your words here]

    List of policies, words about each, and link to each policy

    1. Finances (copayments, deductibles)

A word about finances: in order to deliver the best care to your child, at reasonable cost to you, our office policy is that payment be made at the time of the office visit.  Health plans and insurance companies require co-payments to be paid at the time of the visit


There may be times when we recommend a course of treatment that is not covered by your particular insurance company.  We, of course, are happy to discuss any options and alternative courses of treatment.  However, please remember that our primary commitment must be to deliver the best medical care to your child.


Payment for services:


Our office policy has always been that patients with private insurance (or health plans with which we do not participate) pay for office visits at the time of service.  As a courtesy, we will be glad to submit the medical claim for you to your insurance company so that you can be reimbursed directly.


b. Missed and late appointments


A $50.00 charge will be applied to appointments missed without a 24-hour advanced notice of cancellation.


c. Late appointments:

Our office policy is to reschedule well visits if your child arrives more than fifteen minutes late.  Please understand that a patient seen before you may have an illness requiring more of our time.  Our goal is to provide ample time to care for all of our patients.  We work very hard to avoid having our patients wait excessively.  We value your time, as well as our own.


d. Annual examinations:

are recommended for all children and young adults.  Please schedule these visits three months in advance, on or near their birthdays.


e. Preparation for toddlers:  


Visits to the doctor for children between 12 and 36 months may be difficult.  One way to help your child prepare for check-ups is to role-play, using one of our names, for several days prior to the visit.  Doctors’ kits, books about visiting the doctor, and talking about your own visits to your doctor, in an age-appropriate manner, may help your young child.  


f. Vaccine policy

  • 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 the vaccines according to our office schedule; these vaccines are also recommended and the schedule supported by the Centers for Disease Control and the American Academy of Pediatrics.
  • 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 a very few 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 pediatricians, and that you can perform as parents/caregivers.  The vaccine schedule, as currently recommended by us, is the result of years and years of scientific study and data gathering on millions of children by our brightest scientists and physicians.
  • I would just copy our vaccine policy:  this is way too wordy!!


That said, we recognize that there has always been and will likely always be controversy surrounding vaccinations.  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 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.  Such an attitude, if it becomes widespread, can lead to tragic results.


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 recognize that the choice may be a very emotional one for some parents.  We will do everything we can to allay any concerns you have about vaccinating your child. 


Should you have doubts, please discuss these with one of us in advance of your visitPlease know that delaying or “breaking up the vaccines” opposes expert recommendations, and places your child (and other children) at risk for significant illness.  It contradicts our medical advice. 


If you refuse to vaccinate your child despite all our efforts, we will ask you to find another physician who shares your views.  We do not keep a list of such physicians nor would we recommend any such physician.  Please recognize that by not vaccinating, you place your child at unnecessary risk for life-threatening illness and disability, and even death.


As medical professionals, we feel very strongly that vaccinating on schedule is the right thing to do for all children, adolescents, and yes, even adults!  Thank you for reading this policy, and the trust you place in us.  Please feel free to raise any questions or concerns you may have about this policy with one of us.



g. After hours and weekends

On weeknight evenings a doctor is always available by phone.  On weekends our practice will share coverage with Drs. Sally Roth, Sari Rotter, or Susan Laster in Brookline. 


We generally return calls within ninety minutes, often less.  You can opt to have us paged immediately if a true medical emergency exists and you must speak with us sooner.  (If for any reason your call is not answered within a period of time that you believe is reasonable, call again.)  


Note that if your child is seen on a weekend in Brookline, the care there will be communicated to us.


After-hours: A physician is available by phone when the office is closed.  Please remember that the on-call physician is providing coverage to several thousand families.  During the week, Doctors Benjamin, Spingarn, and Rottenberg share this responsibility in the evening.  Over weekends and holidays, call is shared between one of us, as well as Doctors Roth, Rotter, and Laster, at 637 Washington Street in Brookline.


The phone number is always the same.  (If our phone service becomes inoperative, their phone number is 617-232-2811).  On a Saturday, Sunday, or holiday (when the office is closed), if your child needs to be seen for care that cannot wait until the office re-opens, please try to call between 8:00 am and 9:00 am. 


h. Referral process

To provide the best care, and maintain continuity of care, we will refer your child to a specialist we know and trust.  Please communicate with us, if you believe your child requires a consultation with a specialist.

If your insurance company requires a referral for specialty care, please be sure that our office has approved the referral beforehand.  


i. Records request and records policy

                        When a copy of a patient’s records need to be obtained, please try to give us two week’s notification.  There is a $25 charge for copying each record.


j. School and camp forms

School and Camp forms are provided at annual examinations.  This form is sufficient for all school and camp activities (and nearly always supplants the form provided to you by schools and camps).  It is considered valid for most activities for twelve months from the exam date.  Make multiple copies of this form for use during the year.  Additional copies will be available for ten dollars each.


  1. Accepting new patients

k. HIPPA Privacy Practices


l. HIPPA Statement

Dwight: I have “cut and pasted” this HIPAA policy; it has lost some of its formating.  What are the benefits/risks of just having a PDF file attachment?




     This Notice describes how medical information about you

     may be used and disclosed and how you can get access to






Each time you or your child visits a hospital, physician or other healthcare provider, a record of the visit is made.  Typically this record contains symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment.  This information, often referred to as the health or medical record, serves as a basis for planning care and treatment and serves as a means of communication among the many healthcare professionals who contribute to you or your child’s care.  Understanding what is in your medical record and how your health information is used helps you to ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosures to others.


We, at The Practice of Jonathan A. Benjamin, M.D. and Roger W. Spingarn, M.D., L.L.C., hereafter referred to as The Practice, pledge to provide you with the highest quality of care and to build a relationship that is based on trust.  This trust includes our commitment to respect the privacy and confidentiality of your health information.


This Notice of our Privacy Practices is being given to you because federal law gives you the right to be told ahead of time about:


  1. How The Practice will handle your medical information;
  2. What our legal duties are related to your medical information;
  3. What your rights are with regard to your medical information.
  4. A method for filing complaints about our privacy practices




When you or your child needs health care, you give information about yourself, your health, or your child’s health to doctors, nurses, and other health care workers and staff.  This information, along with the record of care you or your child receives, is “protected health information” (or “health information).  This information is kept in a paper form such as your medical record and in an electronic form on the computer.




  1. The Practice uses and discloses (shares) health information for many different reasons.  For some of these uses and disclosures, we will need to obtain prior written authorization (permission).  However, The Practice may legally use or disclose your or your child’s health information for treatment, payment, and health care operations.  We do not need to receive prior authorization for uses and disclosures described within the following categories:


   For each category of uses or disclosures we will explain what we mean and try to give some examples.  Not every use or disclosure in a category will be listed.  However, all of the ways we are permitted to use and disclose information will fall within one of the categories:


For treatment.  We may use medical information about you or your child to provide you with medical treatment or services.  We may disclose (share) this medical information to other doctors, and health care providers involved in your care.  Example: A primary care physician may refer your child to a specialist such as a radiologist or a surgeon.  The specialist may tell you that your child needs to be admitted to the hospital for treatment or surgery.  All of the doctors in this example will share medical information about you. This is to coordinate care before, during and after your child goes into the hospital.


For payment.  We may use and disclose (share) you or your child’s health information in order to bill and collect payment for the treatment and services provided you or your child.  Example:  A bill may be sent to you or a third party payer.  If you have health insurance, information on or accompanying the bill may include a portion of you or your child’s health information that identifies you or your child, as well as, you or your child’s diagnosis, procedures and supplies used for treatment.  The insurance company uses the information to tell if you are or your child is eligible for benefits or if the services you received were medically needed for payment purposes. We may also provide your or your child’s health information to our business associates, such as a billing company, claims processing companies and, others that process our health care claims.


For health care operations.  We may disclose (share) your health information for activities that are known as health care operations.  These activities use health care information for the purpose of evaluating our performance and finding better ways to provide care.  We may use you or your child’s health information in order to evaluate the quality of health care services that you or your child received or to evaluate the performance of the health care professionals who provided health care services.  We may also share this health information with outside parties (“business associates”) who perform services on behalf of The Practice. These business associates must agree to keep your health information private.  Examples of activities that make up health care operations include; legal counsel, transcription, storage, auditing, and consulting services.


  1. Other uses of your health information. The Practice may use your health information to contact you about;


  • scheduled appointments, registration/insurance updates, pre-procedure assessments or test results;
  • with information about patient care issues and treatment choices;
  • with other health-related benefits and services that may be of interest to you.


  1. We may disclose (share) this health information to others without your consent in certain situations.  Example: If you or your child needs emergency treatment, or if you or your child are unable to communicate with us (unconscious or in severe pain).  In each of these situations we will try to get your consent. But, if you are unable to agree or disagree to consent and if we think you would consent if you were able to do so, we will disclose health information without consent.


  1. Other Specific Uses and Disclosures that DO NOT REQUIRE YOUR CONSENT.


  1. When disclosure of health information is required by federal, state, or local law, administrative or legal proceedings, health oversight activities, or by law enforcement. Examples of some required reporting include: health information about victims of abuse, neglect, or domestic violence: patients with gunshot and or other wounds.  In addition we disclose health information when ordered in a legal or administrative proceeding.


  1. For public health activities.  As required by law, we may disclose health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.  Example, we report information about births, deaths, and various diseases to the government officials in charge of collecting that data consistent with applicable law to carry out their duties.


  1. For business associates.  There are some services provided in our practice through contracts with business associates.  Examples include medical laboratories and radiology facilities. When these services are contracted, we may disclose your or your child’s health information to our business associates so that they can perform the job we have requested them to do and, bill you or a third party payer for services rendered.


  1. For purpose of organ donation.  Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in procuring, banking, or transplantation of organs, eye or tissue donation and transplants.


  1. For research purposes.  In certain circumstances this practice may provide health information in order to conduct or participate in medical research.  Your or your child’s health information will only be used/or disclosed to researchers when their research has been approved by an Institutional Review Board (IRB) that has reviewed the research proposal and established protocols to ensure the privacy of your health information.  An example of this research would be to assess the outcomes of patients who had received specific therapy treatments.


  1. To avoid harm.  In order to avoid a serious threat to the health or safety of a person or the public, we may provide health information to law enforcement personnel or persons able to prevent or lessen such harm.


For specific government functions.  We may disclose health information of military personnel and veterans in certain situations.  And we may disclose health information for national security purposes, such as protecting the president of the United States or conducting intelligence operations.


  1. For worker’s compensation purposes. We may provide health information to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs.


  1. Appointment reminders and health related-benefits or services.  We may use health information to provide appointment reminders or give you information about, treatment alternatives, or other health care services or benefits we offer.


  1. The Use and Disclosure Requiring You to Have the Opportunity to Object.


Disclosure to family, friends or others.  The Practice, using its best judgment,

may disclose health information to a family member, friend, or other person that you indicate, unless you object in whole or in part, health information relevant to that person’s involvement in your care or payment related to your care.  The opportunity to get your authorization may be obtained retroactively in emergency situations.


  1. All Other Uses and Disclosures Require Your Prior Written Authorization.  In any other situation not described in sections 1 (A) through (E), we will ask for your written authorization before using or disclosing any of your health information.




The Practice is required by law to:

  • Make sure that medical information that identifies you is kept private.
  • Provide you with this notice that explains our privacy practices and how, when, and why we use and/or disclose (share) your health information.
  • Follow the terms of the Notice currently in effect.  However, we reserve the right to change our privacy policies and the terms of this notice at any time.  Any changes will apply to the health information we already have.  Before any important policy change goes into effect, we will change this Notice, the new Notice will be posted in a clearly visible location within our practice site(s) for public viewing.
  • You may request a copy of this notice at any time from our The Practice.



Unless otherwise required by law your or your child’s health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you.  You have the right to:


  1. Request Limits on Uses and Disclosures of Your Health Information: You have the right to ask for restrictions on the use and disclosure (sharing) of this health information for treatment, payment or health care operations. We will consider your request but are not legally required to accept it.  If we accept your request, we will put any limits in writing and abide by them except in emergency situations.  You may not limit the uses and disclosures that are legally required or allowed to make.


  1. The Right to ask that Your Health Information Be Communicated to You in a Confidential Manner: You have the right to ask for your or your child’s health information to be sent to you in different ways.  For example you may ask for the Practice to contact you by mail rather than telephone, or only call at your home rather than at work.  Your request must be in writing and explain the method of contact and location where your wish to be contacted.  We will try to honor your request so long as we can easily provide it in the format you request.


  1. The Right to See and Get Copies of Your Health Information: In most cases, you have the right to look at or get copies of your PHI that we have, but you must make the request, in writing.  We will respond within thirty (30) days from the receipt of your request. If you ask for a copy of your records, you will be charged a fee as specific in our policy posted by the front office window. If your request is denied, we will inform you, in writing, our reasons for the denial and explain your right to have the denial reviewed. We may offer to give you a summary or explanation of the information your requested as long as you agree in advance to this and to any fees that this might cost.  If you ask for information we do not have, but we know where it is, we must tell you where to direct your request.


  1. The Right to Receive an Accounting of Disclosures (a record of when and to whom, your health information was shared without your authorization).  You have the right to obtain a list of the instances that we have shared your or your child’s health information.  You must make this request in writing.  You may request as far back as six years, beginning April 14, 2003.  The listing you get will include the date, name, and address (if known) of the person or organization receiving it.  It will also include a brief description of the information given, a brief statement on why the information was shared, or a copy of the written request for the information.


The list will not include uses or disclosures that you have already consented to, such as those made for the treatment, payment, or health care operations, directly to you or your family.  The list also will not include uses or disclosures made for national security purposes, to corrections or law enforcement personnel, or before April 14, 2003.


We have 60 days to respond to your written request. If we are not act on your request within the 60 days, we will notify you that we are extending the response time by 30 days.  If we do that we will explain the delay in writing and give you a new date of when to expect a response. We will provide this list at no charge, but if you make more that one request in the same year, we will charge you for each additional request.


  1. The Right to Correct or Update your Health Information.  If you believe that there is a mistake in your or your child’s health information or that a piece of important information is missing, you have the right to request that we correct the existing information or add the missing information.   You must provide the request and your reason for the request in writing. 


We have 60 days to respond to your request.  We may deny your request, in writing, if the health information is; (i) correct and complete, (ii) not created by us, (iii) not allowed to be disclosed, or (iv) not part of our records.  Our written denial will state the reasons for the denial and explain your rights to file a written statement of disagreement with the denial.  If you do not file a written statement of disagreement, you have the right to request that your request and our denial be attached to all future disclosures of your health information.  .




If you think that The Practice may have violated your privacy rights, or your disagree with a decision we made about access to your health information, you may file a complaint with us. You also may send a written complaint to either:


                                    Office for Civil Rights – Region I Office:

               Office for Civil Rights

               U.S. Department of health and Human Services

               Government Center

J.F. Kennedy Federal Building – Room 1875

Boston, Massachusetts 02203

Or to the,

Secretary of the Department of Health and Human Services

200 Independence Avenue

S.W. Washington, D.C. 20201

Or e-mail the HHS Secretary at HHS.Mail@hhs.gov


The Practice will take no retaliatory action against you if you file a complaint about our privacy practices.



If you have any questions about this notice or any complaints about our privacy practices, or would like to know how to file a complaint with the Secretary of Health and Human Services, please contact Dr. Jonathan A. Benjamin or Dr. Roger W. Spingarn, 1400 Centre Street, Suite 203, Newton, Massachusetts 02459.