King Street Back & Neck Care
Notice of Privacy Practices
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.
Our practice is dedicated, and applicable federal
and state laws require us, to maintain the privacy of your health information.
These laws also require us to provide you with this Notice of Privacy
Practices, and to inform you of your rights, and our obligations, concerning
your health information. We are required to follow the privacy practices
described below while this Notice is in effect. This Notice is effective
as of April 14, 2003, and will remain in effect until we replace it.
Changes to Notice:
We reserve the right to change this Notice and the
privacy practices described below at any time in accordance with applicable
law. Prior to making significant changes to our privacy practices, we
will alter this Notice to reflect the changes, and make the revised Notice
available to you on request. Any changes we make to our privacy practices
and/or Notice may be applicable to health information created or received
by us prior to the date of the changes.
You may request a copy of our Notice at any time.
For more information about our privacy practices, or for additional copies
of this Notice, please contact us using the information listed at the
end of this Notice.
Permitted Uses and Disclosures of Health Information:
A. TREATMENT, PAYMENT, HEALTH CARE OPERATIONS: You should
be aware that during the course of our relationship with you we likely
use and disclose health information about you for treatment, payment,
and healthcare operations. Examples of these activities are as follows:
- Treatment: We may use or disclose your health information
to a physician or other healthcare provider providing treatment to you.
- Payment: We may use and disclose your health information
to obtain payment for services we provide to you.
- Healthcare Operations: We may use and disclose your
healthcare information in connection with our healthcare operations.
Healthcare operations include quality assessment and improvement activities,
reviewing the competence or qualifications of healthcare professionals,
evaluating practitioner and provider performance, and other business
operations.
B. AUTHORIZATIONS: You may specifically authorize us
to use your health information for any purpose or to disclose your health
information to anyone by submitting such an authorization in writing.
Upon receiving an authorization from you in writing we may use or disclose
your health information in accordance with that authorization. You may
revoke an authorization at any time by notifying us in writing. Your revocation
will affect any use or disclosures permitted by your authorization while
it was in effect. Unless you give us a written authorization, we cannot
use or disclose your health information for any reason except those permitted
by this Notice.
C. DISCLOSURES TO FAMILY AND PERSONAL REPRESENTATIVES: We
must disclose your health information to you, as described in the Patient
Rights section of this Notice. Such disclosures will be made to any of
your personal representatives appropriately authorized to have access
and control of your health information. We may disclose your health information
to a family member, friend or other person to the extent necessary to
help with your healthcare or with payment for your healthcare only if
authorized to do so. In the event of your incapacity or in emergency circumstances,
we will disclose health information based on a determination using our
professional judgement disclosing only health information that is directly
relevant to the person’s involvement in your healthcare.
D. MARKETING: We will not use your health information
for marketing communications without your written authorization.
E. USES OR DISLCOSURES REQUIRED BY LAW: We may use or
disclose your health information when we are required to do so by law,
including for public health reasons ( e.g. disease reporting). In some
instances, and in accordance with applicable law, we may be required to
disclose your health information to appropriate authorities if we reasonably
believe that you are a possible victim of abuse, neglect, or domestic
violence or the possible victim of other crimes.
F. PATIENT AND THIRD PARTY PROTECTION: Only as permitted
by law, we may disclose your health information to the extent necessary
to avert a serious threat to your health or safety and health of others.
G. LAW ENFORCEMENT/ NATIONAL SECURITY: Under certain
circumstances we may disclose health information relating to members of
the Armed Forces to military authorities. Under certain circumstances
we may also disclose health information relating to inmates or patients
to correctional institutions or law enforcement personnel having lawful
custody of those individuals. We may disclose health information in response
to judicial proceedings and law enforcement inquiries as permitted by
law and to authorized federal officials health information required for
lawful intelligence, counterintelligence, and other national security
activities.
H. APPOINTMENT REMINDERS: We may disclose your health
information to provide you with appointment reminders (such as voicemail
messages, postcards, or letters).
I. TREATMENT AREA: This office utilizes an open treatment
area for ongoing patient care. An open treatment area involves several
patients being seen in the same area at the same time. Patients are within
sight of one another and some ongoing routine details of care are discussed
within earshot of other patients and staff. The open treatment area is
used for ongoing care and this is not the environment used for taking
histories, providing examinations or presenting reports of findings. If
you choose not to be adjusted in the open treatment area, other arrangements
will be made for you.
Patient Rights
A. ACCESS TO RECORDS: Upon submission of a written request
to us, you have the right to review or receive copies of your health information,
with limited exceptions. You may obtain a form to request access by using
the contact information listed at the end of this Notice. You may request
that we provide copies in a format other than photocopies and we will
use the format you request if it is readily available. We will charge
you a reasonable cost-based fee relating to the production of such copies.
If you request copies, we will charge you (i) $.50 per page for the first
fifty (50) pages and $. 25 per page thereafter for copies from paper,
(ii) $1.00 per page for copies from microfilm; (iii) the actual cost of
copying X-rays; and (iv) postage if you want the copies mailed to you.
If you request an alternative format, we will charge a reasonable cost-based
fee for providing your health information in that format. If you prefer,
we will prepare a summary or an explanation of your health information
for a fee. Contact us using the information listed at the end of this
Notice if you are interested in receiving a summary of your information
instead of copies.
B. ACCOUNTING OF CERTAIN DISCLOSURES. Upon written request,
you have the right to receive a list of instances in which we or our business
associates disclosed your health information for purposes, other than
treatment, payment, healthcare operations and other activities authorized
by you, for the last 6 years, but not before April 14, 2003. If you request
this accounting more than once in a 12- month period, we may charge you
a reasonable, cost-based fee for responding to these additional requests.
C. RESTRICTIONS AND ALTERNATIVE COMMUNICATIONS: You
have the right to request that we place additional restrictions on our
use or disclosure of your health information for treatment, payment and
healthcare operations purposes. Depending on the circumstances of your
request we may, or may not agree to those restrictions. You have the right
to request that we communicate with you about your health information
by alternative means or to alternative locations (e.g., at your place
of business rather than at your home). Such requests must be made in writing,
must specify the alternative means or locations, and must provide satisfactory
explanation how payments will be handled under the alternative means or
location you request.
D.AMENDMENTS TO RECORDS: You have the right to request
that we amend your health information. Such requests must be made in writing,
and must explain why the information should be amended. We may deny your
request under certain circumstances.
E. ELECTRONIC NOTICES: If you receive this Notice on
our Web-site or by electronic mail (e-mail), you are entitled to receive
this Notice in written form.
Questions and Complaints
If you want more information about out privacy practices
or have questions or concerns, please contact us. If you are concerned
that we may have violated your privacy rights, or you disagree with a
decision we made or any decisions we may make regarding the use, disclosure,
or access to your health information you may complain to us using the
contact information listed 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 such a complaint upon request.
We support your right to the privacy of your health
information. We will not retaliate in anyway if you choose to file a complaint
with us or with the U.S Department of Health and Human Services.
Please direct any of your questions or complaints
to:
Contact: Lisa Roske
Telephone: (703) 578-1900 Fax (703) 578-0982
Address: 3690M King Street, Alexandria, VA 22302
Copyright @ 2002 Brown Rudnick eSolutiuons, LLC. All Rights Reserved
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