Maple Pediatrics NY PLLC
Notice of Privacy Practices
Effective date: 10/1/2026
This notice describes how medical information about your child may be used and disclosed and how you can access this information. Please review it carefully.
Who we are
Maple Pediatrics NY PLLC (“Maple Pediatrics” or “the Practice”), whose physician is Despina Tsevdos, MD, is committed to maintaining the privacy and security of your child’s protected health information (“PHI”).
The Practice is required by applicable law to maintain the privacy and security of PHI, provide notice of our legal duties and privacy practices, notify affected individuals following certain breaches of unsecured PHI, and follow the terms of the Notice currently in effect.
Your child’s health information is protected by applicable federal and New York law.
How we may use and disclose health information
Treatment
We may use and disclose your child’s health information to provide, coordinate, and manage medical care.
We may share relevant information with other professionals and organizations involved in your child’s treatment, including specialists, laboratories, imaging centers, pharmacies, hospitals, therapists, and other health care providers.
Example: Dr. Tsevdos may send relevant medical history and a visit summary to a pediatric cardiologist involved in your child’s care.
Payment
We may use and disclose health information to bill for and obtain payment for services provided to your child.
This may include billing you or another person responsible for payment, processing payments, collecting amounts owed, providing itemized receipts or other requested documentation, verifying insurance coverage, submitting claims when applicable, and responding to requests from a health plan, insurer, or other payer.
Example: If insurance billing applies to a particular service, we may provide relevant information to a health plan so that the claim can be processed. We may also provide documentation reasonably needed for a claim or reimbursement request submitted by you.
Nothing in this Notice requires the Practice to participate with an insurance plan, accept insurance for a particular service, or submit a claim on a family’s behalf.
Health care operations
We may use and disclose health information as necessary to operate the Practice and improve the care we provide.
These activities may include quality review, care coordination, scheduling, appointment reminders, secure patient communications, record-keeping, training, legal and accounting services, compliance, business administration, and evaluating Practice services.
We may share PHI with business associates that perform services for the Practice, such as our electronic medical record vendor, secure communications platform, payment processor, billing service, information-technology provider, legal counsel, or accountant.
When required by law, these organizations must agree to safeguard PHI.
Other uses and disclosures permitted or required by law
Public health activities
We may disclose your child’s health information for authorized public-health purposes, including:
Reporting immunizations to the New York Citywide Immunization Registry or New York State Immunization Information System
Communicable-disease reporting and prevention
Newborn-screening follow-up
Reporting adverse reactions to medications or medical products
Assisting with product recalls
Notifying people who may have been exposed to or may be at risk of contracting a disease
Abuse or neglect
We may disclose information to an appropriate government authority when permitted or required by law, including when reporting suspected child abuse or neglect as required of physicians and other mandated reporters under New York Social Services Law § 413.
Serious threats to health or safety
We may disclose information when permitted by law to prevent or reduce a serious threat to a person’s health or safety.
Health oversight
We may disclose information to authorized health-oversight agencies for activities such as audits, investigations, inspections, professional discipline, credentialing, and licensure reviews.
Judicial and administrative proceedings
We may disclose information in response to a court or administrative order.
We may also respond to a subpoena, discovery request, or other lawful process when applicable legal requirements and privacy protections have been satisfied.
Law enforcement
We may disclose information to law-enforcement officials in the limited circumstances permitted or required by law, including in response to qualifying legal process or to report certain injuries or crimes.
Coroners, medical examiners, and funeral directors
We may disclose information to a coroner, medical examiner, or funeral director as permitted by law.
Workers’ compensation
We may disclose information as authorized by and as necessary to comply with workers’ compensation and similar programs.
Research
We may use or disclose health information for research when the research has received the approvals or waivers required by law or when you provide written authorization.
Organ and tissue donation
We may disclose information to organ-procurement organizations or other organizations involved in the procurement, banking, or transplantation of organs, eyes, or tissue as permitted by law.
Specialized government functions
We may disclose information for specialized government functions permitted by law, including certain military, national-security, intelligence, protective-service, and correctional-institution activities.
Compliance with the law
We will disclose health information when federal, state, or local law requires us to do so.
Family members, caregivers, and others involved in care
We may share information directly relevant to a person’s involvement in your child’s care or payment for care with a parent, legal guardian, caregiver, family member, close friend, or another person identified by you, when permitted by law.
When appropriate, we will give you or your child an opportunity to agree or object before making such a disclosure.
If you or your child cannot communicate a preference, such as during an emergency, we may use professional judgment to determine whether sharing limited relevant information is in your child’s best interests.
Minors and confidential services
Parents and legal guardians generally act as the personal representatives of their minor children and may exercise privacy rights on their behalf. However, federal and New York law provide exceptions in certain circumstances.
New York law allows minors to consent independently to certain health services, which may include particular sexual and reproductive health, mental-health, substance-use, and other legally authorized services (see, e.g., N.Y. Public Health Law §§ 2504, 2305, and 2781; N.Y. Mental Hygiene Law §§ 22.11 and 33.21).
When a minor has the legal authority to consent to care or control the related health information, the Practice will follow applicable law regarding access to and disclosure of that information. Health information relating to HIV status is subject to additional confidentiality protections under New York Public Health Law Article 27-F. Except as permitted by law, we will not disclose HIV-related information without a specific written release that meets Article 27-F's requirements, separate from a general authorization to release other medical records.
The Practice may also decline to treat a person as a child’s personal representative when permitted by law, including in certain circumstances involving suspected abuse, neglect, endangerment, or when doing so would not be in the child’s best interests.
Uses and disclosures requiring written authorization
We generally will not use or disclose your child’s PHI for the following purposes without written authorization:
Marketing, when authorization is required by law
The sale of PHI
Most uses or disclosures of psychotherapy notes, if the Practice maintains any
Genetic test results, except as permitted by applicable law
Other uses or disclosures not described in this Notice, unless otherwise permitted or required by law
The Practice does not use patient information for fundraising.
You may revoke an authorization at any time by submitting a written revocation to the Practice. A revocation will not affect actions already taken in reliance on the authorization.
Your privacy rights
Subject to applicable law and any limitations concerning confidential care consented to by a minor, you or your child’s legally authorized personal representative have the following rights.
Right to inspect and obtain a copy
You may ask to inspect or obtain an electronic or paper copy of your child’s medical record and other health information maintained by the Practice.
If you ask to inspect your child's record, we will give you the opportunity to do so within 10 days of receiving your written request, as required by New York law. If you ask for a copy, we will provide it within a reasonable time and no later than 30 days after receiving your request. We may extend this period by one additional 30-day period if we notify you in writing of the reason for the delay and the expected completion date before the initial 30 days expire. A reasonable, cost-based fee may apply as permitted by law. Under New York law, paper copies cost no more than $0.75 per page, and we will not deny a request because of inability to pay. New York law (N.Y. Public Health Law § 18) also provides an independent right to access certain patient information maintained by health care providers.
You also have the right to direct a copy of your child’s electronic health records to a designated third party (such as another health care provider or a personal health record application) at the time you make your request. We will fulfill such requests when the third party is clearly and specifically identified.
Right to request an amendment
You may ask us to correct health information that you believe is incorrect or incomplete.
We may deny the request in certain circumstances permitted by law. If we deny the request, we will explain the reason in writing, and you may have the right to submit a statement of disagreement.
Right to an accounting of disclosures
You may request a list of certain disclosures of your child’s PHI made during the six years before the date of your request.
The accounting generally will not include disclosures made for treatment, payment, or health care operations; disclosures made to you; disclosures you authorized; and certain other disclosures excluded by law.
Right to request restrictions
You may ask us to restrict certain uses or disclosures of PHI for treatment, payment, or health care operations. We generally are not required to agree to your request.
If you pay in full out of pocket for a particular health care item or service, you may ask us not to disclose information about that item or service to a health plan for payment or health care operations. We will agree when required by law, unless another law requires the disclosure.
Right to request confidential communications
You may ask us to communicate with you about your child’s health information in a particular manner or at a particular location. We will accommodate reasonable requests.
Right to choose a personal representative
A person with legal authority to act on behalf of your child may exercise applicable privacy rights and make choices regarding your child’s health information.
We may request documentation establishing that authority.
Right to a paper copy of this Notice
You may obtain a paper copy of this Notice at any time, even if you previously agreed to receive it electronically.
Right to be notified of a breach
You have the right to be notified no later than 60 days after discovery of a breach of your child’s unsecured PHI, as required by law. The notice will describe the breach, the types of information involved, steps you may take to protect yourself, what the Practice is doing to address the situation, and whom to contact with questions. The Practice will also comply with the New York SHIELD Act (NY Gen. Bus. Law § 899-aa), which may impose additional breach notification obligations.
Our duties
The Practice is required to maintain the privacy and security of PHI, provide this Notice, notify affected individuals following a breach of unsecured PHI when required by law, and follow the terms of the Notice currently in effect.
We reserve the right to change the terms of this Notice and make the revised Notice effective for all PHI we maintain, including information created or received before the revised Notice took effect.
If we materially change this Notice, the current version will be available through our patient portal upon request.
When the Practice maintains a physical patient-service location, the current Notice will also be available there as required by law.
Substance use disorder records subject to 42 C.F.R. Part 2
To the extent the Practice creates, maintains, or receives substance use disorder patient records that are subject to 42 C.F.R. Part 2, those records receive additional confidentiality protections under federal law.
Federal law (42 U.S.C. § 290dd-2 and 42 C.F.R. Part 2, “Part 2”) provides additional confidentiality protections for substance use disorder (SUD) patient records.
When your consent is required
We generally must obtain your written consent before using or disclosing SUD records for most purposes. A single consent may authorize disclosures for treatment, payment, and health care operations (TPO). You may revoke a consent at any time except to the extent the Practice has already acted on it.
Disclosures without consent
We may disclose SUD records without consent only in limited circumstances permitted by Part 2: medical emergencies; audits and oversight by government agencies; court orders accompanied by a subpoena or other mandate; reports of crimes or threats of crimes on Practice premises; and mandatory reports of suspected child abuse or neglect.
Prohibition on re-disclosure
Any person or entity that receives SUD records from us is prohibited from re-disclosing them except as permitted by Part 2 or with your written consent. Records disclosed under a TPO consent may be re-disclosed only as permitted by HIPAA, except that they may not be used in civil, criminal, administrative, or legislative proceedings against the patient without the patient’s written consent or a court order.
Your rights regarding SUD records
In addition to the rights described elsewhere in this Notice, you have the right to: consent to or withhold consent for most uses and disclosures of SUD records; and revoke a consent previously given. To ask questions or exercise these rights, contact the Privacy Officer listed in the Questions and Complaints section below.
Questions and complaints
If you have questions about this Notice, would like to exercise a privacy right, or believe your child’s privacy rights have been violated, please contact:
Privacy Officer Despina Tsevdos, MD
Maple Pediatrics NY PLLC
917-725-0787
Email: drtsevdos@maplepediatricsny.com
You may also file a complaint with:
U.S. Department of Health and Human Services Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
Telephone: 1-800-368-1019
Online: hhs.gov/ocr
The Practice will not retaliate against you or your child for filing a complaint or exercising a privacy right.