NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
you have any questions about this Notice, please contact our
Forest Avenue # 401
Richmond, VA 23229-4937
Jahnke Road #270
Richmond, VA 23225
We understand that medical information about you and your
health is personal and we are committed to protecting that
information. We create a record of the care and services you
receive at the Medical Practice in order to provide you with
quality care and to comply with certain legal requirements.
Notice of Privacy Practices describes how we may use and disclose
medical information about you, including demographic information,
that may identify you and your related health care services
to carry out your treatment, obtain payment for our services,
to perform the daily health care operations of this practice
and for other purposes that are permitted or required by law.
This notice also describes your rights to access and control
your medical information.
are required to abide by the terms of this Notice of Privacy
You will be asked to sign a written statement acknowledging
that you have received a copy of this notice. The acknowledgement
only serves to create a record that you have received a copy
of this notice.
Changes to this Notice
We may change the terms of our Notice, at any time. The new
Notice will be effective for all medical information that
we maintain at that time. Upon your request, we will provide
you with any revised Notice of Privacy Practices. To request
a revised copy, you may call our office and request that a
revised copy be sent to you in the mail or you may ask for
one at the time of your next appointment.
How We May Use and Disclose Medical Information about You
The following categories describe the different ways that
the Medical Practice may use and disclose your medical information
and a few examples of what we mean. These examples are not
meant to describe every circumstance, but to give you an idea
of the types of uses and disclosures that may be made by our
office. Other uses and disclosures of your medical information
that are not listed or described below will be made only with
your written authorization. You may revoke this authorization,
at any time, in writing, but it will not apply to any actions
we have already taken.
For your treatment: Your medical information may
be used and disclosed by us for the purpose of providing
medical treatment to you or for another health care provider
providing medical treatment to you. For example, a nurse
obtains treatment information about you and documents it
in your medical record and the physician has access to that
information. If you require an x-ray to be taken, the x-ray
technician also has access to your medical information.
In addition, your medical information may be provided to
a physician to whom you have been referred or are otherwise
seeing to ensure that the physician has the necessary information
to diagnose or treat you.
To obtain payment for our services: Your medical
information may be used and disclosed by us to obtain payment
for your health care bills or to assist another health care
provider in obtaining payment for their health care bills.
For example, we may submit requests for payment to your
health insurance company for the medical services that you
received. We may also disclose your medical information
as required by your health insurance plan before it approves
or pays for the health care services we recommend for you.
our health care operations: Your medical information
may be used and disclosed by us to support our daily operations.
These health care operation activities include, but are
not limited to, quality assessment activities, employee
review activities, training of medical students, licensing,
and conducting or arranging for other business activities.
For example, we may disclose your medical information to
medical school students that see patients at our office.
We may also use the medical information we have to determine
where we can make improvements in the services and care
the health care operations of other health care providers:
We may also use your medical information to assist
another health care provider treating you with its quality
improvement activities, evaluation of the health care professionals
or for fraud and abuse detection or compliance. For example,
we may disclose your medical information to another physician
to assist in its efforts to make sure it is complying with
all rules related to operating a medical practice.
For appointment reminders: We may use or disclose
your medical information to contact you to remind you of
your appointment, by mail or by telephone. Our message will
include the name of our practice or the name of our physician
as well as the date and time for your appointment or a reminder
that an appointment needs to be scheduled.
provide you with treatment alternatives: We may
use or disclose your medical information to provide you
with information about treatment alternatives or other health-related
benefits and services that may be of interest to you. For
example, we may contact several home health agencies or
physical therapy providers to discuss the services they
provide when we have a patient who needs these services.
our business associates: We will share your medical
information with third party "business associates"
that perform various activities (e.g., billing, transcription
services) for the practice. Whenever an arrangement between
our office and a business associate involves the use or
disclosure of your medical information, we will have a written
agreement that contains terms that will protect the privacy
of your medical information. For example, the Medical Practice
may hire a billing company to submit claims to your health
care insurer. Your medical information will be disclosed
to this billing company, but a written agreement between
our office and the billing company will prohibit the billing
company from using your medical information in any way other
than what we allow.
Involved in Your Health care: Unless you object,
we may disclose to a member of your family, a relative,
a close friend or any other person you identify, your medical
information that directly relates to that person's involvement
in your health care. If you are unable to agree or object
to such a disclosure, we may disclose such information as
necessary if we determine that it is in your best interest
based on our professional judgment. We may use or disclose
your medical information to notify a family member or any
other person that is responsible for your care of your location
and general health condition. Finally, we may use or disclose
your medical information to an authorized public or private
entity to assist in (1) disaster relief efforts and (2)
to coordinate uses and disclosures to family or other individuals
involved in your health care.
required by law: We may use or disclose your medical
information to the extent that the use or disclosure is
required by law. The use or disclosure will be made in compliance
with the law and will be limited to the relevant requirements
of the law. You will be notified, as required by law, of
any such uses or disclosures.
public health activities: We may disclose your
medical information for public health activities and purposes
to a public health authority that is permitted by law to
collect or receive the information. The disclosure will
be made for the purpose of controlling disease, injury or
disability. We may also disclose your medical information,
if directed by the public health authority, to any other
government agency that is collaborating with the public
required by the Food and Drug Administration: We
may disclose your medical information to a person or company
required by the Food and Drug Administration to report adverse
events, product defects or problems, biologic product deviations,
or to track products; to enable product recalls; to make
repairs or replacements; or to conduct post marketing surveillance,
communicable disease exposure: We may disclose
your medical information, if authorized by law, to a person
who may have been exposed to a communicable disease or may
otherwise be at risk of contracting or spreading the disease
your employer: We may disclose your medical information
concerning a work related injury or illness to your employer
if you are covered under your employer's policy in order
to conduct an evaluation relating to medical surveillance
of the work place or to evaluate whether you have a work-related
injury, in accordance with the law.
abuse or neglect: We may disclose your medical
information to a public health authority that is authorized
by law to receive reports of child or adult abuse or neglect.
In addition, we may disclose your medical information if
we believe that you have been a victim of abuse, neglect
or domestic violence as may be required or permitted by
Virginia and/or federal law.
health oversight: We may disclose your medical
information to a health oversight agency for activities
authorized by law. Oversight agencies seeking this information
include government agencies that oversee the health care
system, government benefit programs (such as Medicare or
Medicaid), other government regulatory programs and civil
In legal proceedings: We may disclose your medical
information in the course of any judicial or administrative
proceeding, in response to an order of a court or administrative
tribunal (to the extent such disclosure is expressly authorized),
and in certain conditions in response to a subpoena or other
For law enforcement: We may also disclose your
medical information, so long as all legal requirements are
met, for law enforcement purposes. Examples of these law
enforcement purposes include (1) information requests for
identification and location purposes, (2) pertaining to
victims of a crime, (3) suspicion that death has occurred
as a result of criminal conduct, (4) in the event that a
crime occurs on the premises of the Practice, and (5) in
an medical emergency where it is likely that a crime has
coroners, to funeral directors, and for organ donation:
We may disclose your medical information to a coroner or
medical examiner for identification purposes, determining
cause of death or for the coroner or medical examiner to
perform other duties authorized by law. We may also disclose
medical information to a funeral director in order to permit
the funeral director to carry out its duties. We may disclose
such information in reasonable anticipation of death. Your
medical information may be used and disclosed for cadaveric
organ, eye or tissue donation purposes.
to criminal activity: Consistent with applicable
federal and state laws, we may disclose your medical information
if we believe that the use or disclosure is necessary to
prevent or lessen a serious and imminent threat to the health
or safety of a person or the public. We may also disclose
your medical information if it is necessary for law enforcement
authorities to identify or apprehend an individual.
military activity and national security: When the
appropriate conditions apply, we may use or disclose medical
information of individuals who are Armed Forces personnel
(1) for activities deemed necessary by appropriate military
command authorities; (2) for the purpose of a determination
by the Department of Veterans Affairs of your eligibility
for benefits; or (3) to foreign military authority if you
are a member of that foreign military services. We may also
disclose your medical information to authorized federal
officials for conducting national security and intelligence
activities, including for the provision of protective services
to the President or others legally authorized.
workers' compensation: Your medical information
may be disclosed by us as authorized to comply with workers'
compensation laws and other similar legally established
inmates: We may use or disclose your medical information
if you are an inmate of a correctional facility and your
physician created or received your medical information in
the course of providing care to you.
required uses and disclosures: Under the law, we
must make disclosures to you and, when required by the Secretary
of the Department of Health and Human Services, to investigate
or determine our compliance with the requirements of the
Health Insurance Portability and Accountability Act and
Following is a statement of your rights with respect to your
medical information and a brief description of how you may
exercise these rights.
have the right to inspect and copy your medical information.
You may inspect and obtain a copy of your medical information
that we maintain. The information may contain medical and
billing records and any other records that we use for making
decisions about you. However, under federal law, you may
not inspect or copy the following records: psychotherapy
notes; information compiled related to a civil, criminal,
or administrative action; and medical information that is
subject to law that prohibits access to medical information
in certain circumstances. We may deny your request to inspect
your medical information. In some circumstances, you may
have a right to have this decision reviewed. Please contact
our Privacy Officer if you have questions about access to
your medical record.
have the right to request a restriction of your medical
information. This means you may ask us not to use
or disclose any part of your medical information for the
purposes of treatment, payment or health care operations.
You may also request that any part of your medical information
not be disclosed to family members or friends who may be
involved in your care. Your request must state the specific
restriction requested and to whom you want the restriction
are not required to agree to your request. If we
agree to the requested restriction, we may not use or disclose
your medical information in violation of that restriction
unless it is needed to provide emergency treatment or unless
we otherwise notify you that we can no longer honor your
request. With this in mind, please discuss any restriction
you wish to request with your physician. Please request
all restrictions in writing to our Privacy Officer.
have the right to request that we accommodate you in communicating
confidential medical information. We will accommodate
reasonable requests, but we may condition this accommodation
by asking you for information as to how payment will be
handled or other information necessary to honor your request.
Please make this request in writing to our Privacy Officer.
may have the right to ask us to amend your medical information.
You may request an amendment of your medical information
as long as we maintain this information. In certain cases,
we may deny your request for an amendment. If we deny your
request for amendment, you have the right to file a disagreement
with us and we may respond in writing to you. Please contact
our Privacy Officer if you have questions about amending
your medical record.
have the right to receive an accounting of certain disclosures
we have made, if any, of your medical information.
This right applies to disclosures for purposes other than
treatment, payment or health care operations as described
in this Notice of Privacy Practices. It excludes disclosures
we may have made pursuant to your authorization (permission),
made directly to you, to family members or friends involved
in your care, or for appointment notification purposes.
You have the right to receive specific information regarding
these disclosures that occurred after April 14, 2003. You
may request a shorter timeframe. The right to receive this
information is subject to certain exceptions, restrictions
have the right to obtain a paper copy of this notice from
us. If you would like a paper copy of this notice,
please request one from our Privacy Officer or request one
when you are in our offices.
You may complain to us if you believe your privacy rights
have been violated by us. To file a complaint, please contact
our Privacy Officer who will be happy to assist you. You may
file a complaint with us by notifying our Privacy Officer
of your complaint. We will not retaliate against you for filing
a complaint. If you do not wish to file a complaint with us,
you may contact the Secretary of Health and Human Services.
If you have any questions about this Notice or require additional
information, please contact our Privacy Officer, at (804)
285-1611 or at 7603 Forest Avenue # 401, Richmond, VA 23229. Our
Privacy Officer is available during normal business hours
to discuss your privacy questions, concerns or complaints.
This notice was published and becomes effective on December