FAMILY PRACTICE, INC
2500 New Kent
Highway, PO Box 7
Quinton, VA 23141
(Office Phone) 804-932-9860 (fax)
NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU
BE USED AND DISCLOSED AND
YOU CAN GET ACCESS TO THIS INFORMATION.
REVIEW IT CAREFULLY.
you have any questions about this Notice, please contact our Privacy Officer:
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
required to abide by the terms of this Notice of Privacy Practices.
2. Written Acknowledgement
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 the 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. The current Notice of Privacy Practices will be also posted on our Web site, www.chickahominyfp.com .
How We May Use and Disclose
Medical Information about You
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.
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.
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, fundraising activities, 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 we offer.
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.
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.
To 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
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
Fundraising Activities: We may use or disclose
your demographic information and the dates that you received treatment from us
in order to contact you for fundraising activities supported by our office.
If you do not want to receive these materials, please contact the Privacy
Officer and request that these fundraising materials not be sent to you.
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
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 health authority.
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, as required.
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 or condition.
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.
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 rights laws.
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 lawful request.
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 occurred.
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.
We may disclose your medical information to researchers when their
research has been established as required by federal and state law.
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.
Your medical information may be disclosed by us as authorized to comply
with workers’ compensation laws and other similar legally established
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 its regulations.
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 inspect and copy your
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.
You 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 to apply.
We 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.
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 to our Privacy Officer.
You may have the right to ask us to amend your
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.
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 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
You 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.
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.
have any questions about this Notice or require additional information, please
contact our Privacy Officer, Mrs. Robertson – Kentwood Square Medical Center
2500 New Kent Highway Quinton, VA 23141
(804) 932-4388. Our
Privacy Officer is available during normal business hours to discuss your
privacy questions, concerns or complaints.
8. Effective Date. This notice was published and becomes effective on April 14, 2003.
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