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. THE
PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.
Uses and Disclosures of Protected Health Information
We will use and disclose your protected health information about you for treatment,
payment, and health care operations.
Following are examples of the types of uses and disclosures of your protected
health care information that may occur. These examples are not meant to be
exhaustive, but to describe the types of uses and disclosures that may be
made by our office.
Treatment: We will use and disclose your protected health
information to provide, coordinate or manage your health care and any related
services. This includes the coordination or management of your health care
with a third party. For example, we would disclose your protected health information,
as necessary, to a home health agency that provides care to you. We will also
disclose protected health information to other physicians who may be treating
you. For example, your protected health information may be provided to a physician
to whom you have been referred to ensure that the physician has the necessary
information to diagnose or treat you.
In addition, we may disclose your protected health information from time to
time to another physician or health care provider (e.g., a specialist or laboratory)
who, at the request of your physician, becomes involved in your care by providing
assistance with your health care diagnosis or treatment to your physician.
Payment: Your protected health information will be used,
as needed, to obtain payment for your health care services. This may include
certain activities that your health insurance plan may undertake before it
approves or pays for the health care services we recommend for you, such as:
making a determination of eligibility or coverage for insurance benefits,
reviewing services provided to you for protected health necessity, and undertaking
utilization review activities. For example, obtaining approval for a hospital
stay may require that your relevant protected health information be disclosed
to the health plan to obtain approval for the hospital admission.
Health Care Operations: We may use or disclose, as needed,
your protected health information in order to conduct certain business and
operational activities. These activities include, but are not limited to,
quality assessment activities, employee review activities, training of students,
licensing, and conducting or arranging for other business activities.
For example, we may use a sign-in sheet at the registration desk where you
will be asked to sign your name. We may also call you by name in the waiting
room when your doctor is ready to see you. We may use or disclose your protected
health information, as necessary, to contact you by telephone or mail to remind
you of your appointment.
We will share your protected health 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 protected health
information, we will have a written contract that contains terms that will
protect the privacy of your protected health information.
We may use or disclose your protected health information, as necessary, to
provide you with information about treatment alternatives or other health-related
benefits and services that may be of interest to you. We may also use and
disclose your protected health information for other marketing activities.
For example, your name and address may be used to send you a newsletter about
our practice and the services we offer. We may also send you information about
products or services that we believe may be beneficial to you. You may contact
us to request that these materials not be sent to you.
Uses and Disclosures Based On Your Written Authorization:
Other uses and disclosures of your protected health information will be made
only with your authorization, unless otherwise permitted or required by law
as described below.
You may give us written authorization to use your protected health information
or to disclose it to anyone for any purpose. If you give us an authorization,
you may revoke it in writing at any time. Your revocation will not affect
any use or disclosures permitted by your authorization while it was in effect.
Without your written authorization, we will not disclose your health care
information except as described in this notice.
Others 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 protected health 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 protected health information
to notify or assist in notifying a family member, personal representative
or any other person that is responsible for your care of your location, general
condition or death.
Marketing: We may use your protected health information to
contact you with information about treatment alternatives that may be of interest
to you. We may disclose your protected health information to a business associate
to assist us in these activities. Unless the information is provided to you
by a general newsletter or in person or is for products or services of nominal
value, you may opt out of receiving further such information by telling us
using the contact information listed at the end of this notice.
Research; Death; Organ Donation: We may use or disclose your
protected health information for research purposes in limited circumstances.
We may disclose the protected health information of a deceased person to a
coroner, protected health examiner, funeral director or organ procurement
organization for certain purposes.
Public Health and Safety: We may disclose your protected
health information to the extent necessary to avert a serious and imminent
threat to your health or safety, or the health or safety of others. We may
disclose your protected health information to a government agency authorized
to oversee the health care system or government programs or its contractors,
and to public health authorities for public health purposes.
Health Oversight: We may disclose protected health information
to a health oversight agency for activities authorized by law, such as audits,
investigations and inspections. Oversight agencies seeking this information
include government agencies that oversee the health care system, government
benefit programs, other government regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose your protected health information
to a public health authority that is authorized by law to receive reports
of child abuse or neglect. In addition, we may disclose your protected health
information if we believe that you have been a victim of abuse, neglect or
domestic violence to the governmental entity or agency authorized to receive
such information. In this case, the disclosure will be made consistent with
the requirements of applicable federal and state laws.
Food and Drug Administration: We may disclose your protected
health information to a person or company required by the Food and Drug Administration
to report adverse events, product defects or problems, biologic product deviations,
to track products; to enable product recalls; to make repairs or replacements;
or to conduct post marketing surveillance, as required.
Criminal Activity: Consistent with applicable federal and
state laws, we may disclose your protected health 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 protected health information if it is necessary for law enforcement
authorities to identify or apprehend an individual.
Required by Law: We may use or disclose your protected health
information when we are required to do so by law. For example, we must disclose
your protected health information to the U.S. Department of Health and Human
Services upon request for purposes of determining whether we are in compliance
with federal privacy laws. We may disclose your protected health information
when authorized by workers’ compensation or similar laws.
Process and Proceedings: We may disclose your protected health
information in response to a court or administrative order, subpoena, discovery
request or other lawful process, under certain circumstances. Under limited
circumstances, such as a court order, warrant or grand jury subpoena, we may
disclose your protected health information to law enforcement officials.
Law Enforcement: We may disclose limited information to a
law enforcement official concerning the protected health information of a
suspect, fugitive, material witness, crime victim or missing person. We may
disclose the protected health information of an inmate or other person in
lawful custody to a law enforcement official or correctional institution under
certain circumstances. We may disclose protected health information where
necessary to assist law enforcement officials to capture an individual who
has admitted to participation in a crime or has escaped from lawful custody.
Patient Rights
Access: You have the right to look at or get copies of your
protected health information, with limited exceptions. You must make a request
in writing to the contact person listed herein to obtain access to your protected
health information. You may also request access by sending us a letter to
the address at the end of this notice. If you request copies, we will charge
you 25¢ for each page, $15.00 per hour for staff time to locate and copy
your protected health information, and postage if you want the copies mailed
to you. If the Practice keeps your health information in electronic form,
you may request that we send it to you or another party in electronic form.
If you prefer, we will prepare a summary or an explanation of your protected
health information for a fee. Contact us using the information listed at the
end of this notice for a full explanation of our fee structure.
Accounting of Disclosures: You have the right to receive
a list of instances in which we or our business associates disclosed your
non-electronic protected health information for purposes other than treatment,
payment, health care operations and certain other activities during the past
six (6) years. For disclosures of electronic health information, our duty
to provide an accounting only covers disclosures after January 1, 2011 [January
1, 2014] and only applies to disclosures for the three (3) years preceding
your request. We will provide you with the date on which we made the disclosure,
the name of the person or entity to whom we disclosed your protected health
information, a description of the protected health information we disclosed,
the reason for the disclosure, and certain other information. If you request
this list more than once in a 12-month period, we may charge you a reasonable,
cost-based fee for responding to these additional requests. Contact us using
the information listed at the end of this notice for a full explanation of
our fee structure.
Restriction Requests: You have the right to request that
we place additional restrictions on our use or disclosure of your protected
health information. Except as noted herein, we are not required to agree to
these additional restrictions, but if we do, we will abide by our agreement
(except in an emergency). We are required to accept and follow requests for
restrictions of health information to insurance companies if you have paid
out-of-pocket and in full for the item or service we provide to you. Any agreement
we may make to a request for additional restrictions must be in writing signed
by a person authorized to make such an agreement on our behalf. We will not
be bound unless our agreement is so memorialized in writing.
Confidential Communication: You have the right to request
that we communicate with you in confidence about your protected health information
by alternative means or to an alternative location. You must make your request
in writing. We must accommodate your request if it is reasonable, specifies
the alternative means or location, and continues to permit us to bill and
collect payment from you.
Amendment: You have the right to request that we amend your
protected health information. Your request must be in writing, and it must
explain why the information should be amended. We may deny your request if
we did not create the information you want amended or for certain other reasons.
If we deny your request, we will provide you a written explanation. You may
respond with a statement of disagreement to be appended to the information
you wanted amended. If we accept your request to amend the information, we
will make reasonable efforts to inform others, including people or entities
you name, of the amendment and to include the changes in any future disclosures
of that information.
Electronic Notice: If you receive this notice on our website
or by electronic mail (e-mail), you are entitled to receive this notice in
written form. Please contact us using the information listed at the end of
this notice to obtain this notice in written form.
Notice of Unauthorized Disclosures: If the Practice causes
or allows your health information to be disclosed to an unauthorized person,
and such may cause harm to you, the Practice will notify you of this and help
you mitigate the effects.
Questions and Complaints
If you want more information about our privacy practices or have questions
or concerns, please contact us using the information below.
If you believe that we may have violated your privacy rights, or you disagree
with a decision we made about access to your protected health information
or in response to a request you made, you may complain to us using the contact
information below. You also may submit a written complaint to the U.S. Department
of Health and Human Services. We will provide you with the address to file
your complaint with the U.S. Department of Health and Human Services upon
request.
We support your right to protect the privacy of your protected health information.
We will not retaliate in any way if you choose to file a complaint with us
or with the U.S. Department of Health and Human Services.
Name of Contact Person: Harris Finkelstein
Telephone: 703-858-7887
Address: 19450 Deerfield Ave., #280 Leesburg, VA 20176