9460 Amberdale Drive, Suite C

Richmond, VA 23236

(804) 276-2470

FAX (804) 276-2473

Notice of Privacy Practices

This 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

If you have any questions about this Notice, please contact our office staff

PURPOSE:

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 in order to provide you with quality care and to comply with certain legal requirements.

This 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 by law. This notice also describes your rights to access and control your medical information.

We are required to abide by the terms of this Notice of Privacy Practices.

WRITTEN ACKNOWLEDGEMENT

You will be asked to sign a written statement acknowledging that you have read a copy of this Notice. The acknowledgment only serves to create a record that you have read a copy of the Notice. If you request a copy of this Notice, one will be provided to you.

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 a revised Notice of Privacy Practices. To request a revised copy, you may call our office and request that a copy is sent to you in the mail or you may ask for one at the time of your next appointment.

HOW WE MAY USE & DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe the different ways that the Practice may use and disclose your medical information. These categories 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 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.
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 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, training of medical students, licensing and conducting or arranging other business activities.
For 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 professional or for fraud and abuse detection or compliance.
For appointment reminders. We may use or disclose your medical information to contact you to remind you of your appointment, but mail or by telephone.
To provide you with treatment alternatives.
To our business associates – We will share your medical information with third party “business associates” that perform various activities (i.e. billing, transcription services, etc.) for this practice.
Others involved in your healthcare. 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 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.
As required by law.
For public health activities. The disclosure will be made for the purpose of controlling disease, injury or disability.
As required by the Food and Drug Administration.
For communicable disease exposure.
To 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 workplace or to evaluate whether you have a work-related injury, in accordance with the law.
For abuse or neglect. We may disclose medical information to a public health authority that is authorized by the law to receive reports of child or adult abuse or neglect.
For health oversight. We may disclose your medical information to a health oversight agency for activities authorized by law.
In legal proceedings, for law enforcement, to coroners, funeral directors and for organ donations.
For research when the research has been established as required by federal or state law.
Due to criminal activity, consistent with applicable federal and state laws.
For military activity and national security.
Regarding inmates, 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.

YOUR RIGHTS

The following is a statement of your rights with respect to your medical information and a brief description of how you may exercise these rights.

You have the right to obtain a copy of your medical information. 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 any questions about access to your medical records.

You have a 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 purpose 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 to apply.

We are not required to agree with 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. Please discuss any restriction you wish to request with your physician.

You 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.

You 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 an amendment, you have the right to file a disagreement with us and we may respond in writing to you.

You 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 the Notice of Privacy Practices. It excludes disclosures we may have made pursuant to your permission made directly to you, to family members or friends involved in your care, or for appointment notification purposes.

COMPLAINTS

You may file a complaint with us if you believe your privacy rights have been violated by us. To file a compliant, please contact our Privacy Officer who will be glad to help you. 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.

PRIVACY CONTACT

If you have any questions about this Notice or require additional information, please contact our Privacy Officer at 804-897-8566.

EFFECTIVE DATE

This Notice was published and becomes effective April 14, 2003.

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