HIPAA Compliance
Published: Apr. 30, 2024


HIPAA Compliance

The Pediatric Associates HIPAA / Compliance page is a resource for patients, caregivers and employees and includes various Patient Forms and Patient Notices. The Patient Forms allow patients to request chart restrictions, copies of their medical records, request to have their medical record amended and request an accounting of medical record disclosures. The Patient Notices describe our Code of Conduct and explain the patient’s rights and our practice’s responsibilities regarding uses and disclosures of Protected Health Information in our Notice of Privacy Practices. Additionally, via our Customer Relations Department, patients may document positive customer service interactions with staff and medical care experiences with our providers; as well as let us know areas where we can improve our level of service to meet patients’ and caregivers’ expectations. Lastly, we are a culturally competent organization and we do not discriminate against patients or their caregivers who identify as having a language barrier or disability.

Download Patient Forms

Below are general forms available to download. To view the forms listed below, you will need Adobe Reader.

You can download Adobe Reader here.


Please call your office directly for required school forms or visit your child’s chart portal.


Por favor, llame directamente a su oficina para obtener los formularios escolares necesarios o visite el portal de registros de su hijo/a.

  • HIPAA Form A – Solicitud para Limitaciones y Restricciones de Informacion de Salud Protegida
  • HIPAA Form C – Solicitud de Correccion/Enmienda de Informacion Medica Protegida
  • HIPAA Form D – Solicitud de Justificacion de Ciertas Divulgaciones de Informacion Medica Protegida para Propositos NO-TPO


Florida law requires that your health care provider or health care facility recognize your rights while you are receiving medical care and that you respect the health care provider’s or health care facility’s right to expect certain behavior on the part of patients. Below you will find copies of Pediatric Associates’ Notice of Rights and Responsibilities and Florida’s Rights and Responsibilities.

Click here to read our Notice of Patient Rights & Responsibilities
Click here to read our Notice of Patient Rights & Responsibilities (Spanish)
Click here to read Florida’s Rights & Responsibilities




We are committed to ensuring that you are satisfied with the care and services you receive at our practice. Please let us know about your experience with us by contacting our Customer Relations Department at (866) 628-2385 or customerservice@pediatricassociates.com .