NOTICE OF PRIVACY PRACTICES
Effective Date: April 14, 2003
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please ask our reception desk staff or the Facility Privacy Officer.
Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing-related information. This notice applies to all of the records of your care generated by our clinic, whether made by clinic personnel, agents of the clinic, or your personal doctor.
We are required by law to maintain the privacy of your health information and provide you a description of our privacy practices. We will abide by the terms of this notice.
Uses and Disclosures
How we may use and disclose Health Information about you.
The following categories describe examples of the way we use and disclose health information:
For Treatment: We may use health information about you to provide you treatment or services. We may disclose health information about you to doctors, nurses, technicians, medical students, or hospital personnel involved with your care at the hospital. For example: During the course of your treatment, our physician may determine that they will need to consult with another specialist in the area. They will share health information with such specialist to obtain their input. We may also provide any other physicians or subsequent healthcare providers with copies of various reports that should assist them in treating you presently or in the future.
For Payment: We may use and disclose health information about your treatment and services to bill and collect payment from you, your insurance company or a third party payer. For example, we may need to give your insurance company information about your condition and treatments so they will properly reimburse for the healthcare services provided by our clinic. We may also tell your health plan or third party payer about any treatments you may receive to determine whether or not your plan will provide benefits for such treatments.
For Health Care Operations: Members of our staff and business associates providing services such as, but not limited to, quality assessment, outcome evaluation, and training programs may use information in your health record to assess the care and outcomes in your case and others like it. For example, we may combine health information about many patients to evaluate the need for new services or treatment. We may disclose information to doctors, nurses, and other students for educational purposes. And we may combine health information we have with that of other health care providers and facilities to see where we can make improvements. We may remove information that identifies you from this set of health information to protect your privacy.
We may also use and disclose health information:
• To business associates we have contracted with to perform the agreed upon service;
• To remind you that you have an appointment for medical care;
• To assess your satisfaction with our services;
• To tell you about possible treatment alternatives;
• To tell you about health–related benefits or services;
• To inform Funeral Directors consistent with applicable law;
• For population based activities relating to improving health or reducing health care costs; and
• For conducting training programs or reviewing competence of health care professionals.
When disclosing information, primarily appointment reminders and billing/collections efforts, we may leave messages on your answering machine/voice mail.
Business Associates: There are some services provided in our organization through contracts with business associates. Examples include our answering service, our transcription service, and our information systems solutions provider. When these services are contracted, we may disclose your health information to our business associates so that they may perform the tasks we have contracted them to do. To protect your health information, however, we require the business associate to appropriately safeguard your information by signing a Business Associate Agreement.
Individuals Involved in Your Care or Payment for Your Care: We may release health information about you to a friend or family member who is involved in your medical care or who helps pay for your care. In addition, we may disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
Future Communications: We may communicate to you via newsletters, mail outs or other means regarding treatment options, health related information, disease-management programs, wellness programs, or other community based initiatives or activities in which our clinic may be participating.
Organized Health Care Arrangement: Our clinic and the staff members have organized and are presenting you this document as a joint notice. Information will be shared as necessary to carry out treatment, payment and health care operations.
As required by law, we may also use and disclose health information for the following types of entities, including but not limited to:
• Food and Drug Administration (FDA)
• Public Health or Legal Authorities charged with preventing or controlling disease, injury or disability
• Correctional Institutions
• Workers Compensation Agents
• Military Command Authorities
• Health Oversight Agencies
• Funeral Directors, Coroners and Medical Directors
• National Security and Intelligence Agencies
• Protective Services for the President and Others
Law Enforcement/Legal Proceedings: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
State-Specific Requirements: Many states have requirements for reporting including population-based activities relating to improving health or reducing health care costs. Some states have separate privacy laws that may apply additional legal requirements. If the state privacy laws are more stringent than federal privacy laws, the state law preempts the federal law.
Your Health Information Rights
While your health and billing records are the physical property of this clinic, the information contained therein belongs to you. Therefore, you have the Right to:
• Inspect and Copy: You have the right to inspect and obtain a copy of the health information that may be used to make decisions about your care. Usually, this includes medical and billing records. This does not include psychotherapy notes. We reserve the right to charge for a copy of your medical records per Va. Code 8.01-413-B. Our charge for this service is $0.50 per page up to 50 pages ($0.25 per page thereafter), a $10 handling fee, and any postage fees incurred.
• Amend: If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment. However, we may deny your request to amend information that:
• Was not created by us, unless the person or entity that created the information is no longer available to make an amendment;
• Is not part of the health information kept by or for the office;
• Is not part of the information that you would be permitted to inspect and copy; or
• Is accurate and complete
If your request is denied, you will be informed in writing of the reason for the denial and you will have the opportunity to submit a statement of disagreement to be maintained with your records.
• An Accounting of Disclosures: You have the right to request an accounting of disclosures. This is a list of certain disclosures we make of your health information for purposes other than treatment, payment or health care operations where an authorization was not required.
• Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information regarding a recent diagnosis or surgery.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
• Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you may ask that we contact you at office instead of your home. The facility will grant reasonable requests for confidential communications at alternative locations and/or via alternative means only if the request is submitted in writing and the written request includes a mailing address where the individual will receive bills for services rendered by the facility and related correspondence regarding payment for services. Please realize that we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.
• A Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
To exercise any of your rights, please obtain the required forms from the reception desk staff or Facility Privacy Officer.
CHANGES TO THIS NOTICE
We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted in the clinic and include the effective date.
If you believe your privacy rights have been violated, you may file a complaint with the clinic by contacting Mary Lindsey, Practice Administrator, at:
3620 Joseph Siewick Dr, Suite 101
Fairfax, VA 22033
Additionally, you may file a complaint with the Secretary of the Department of Health and Human Services.
All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
OTHER USES OF HEALTH INFORMATION
Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.