NOTICE OF PRIVACY PRACTICES
Last modified: July 28, 2021
Effective Date: January 1, 2012
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.
Your health record contains personal information about you and your health. Information about you that may identify you and that relates to your past, present, or future physical or mental health and related health care services is referred to as Protected Health Information (“PHI”). I am dedicated to maintaining the privacy of your PHI as part of providing professional care. This Notice describes how I may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and Maryland law. It also describes your rights regarding how you may gain access to and control your PHI. I will follow the privacy practices described in this Notice. If I amend this notice, I will furnish you with the amended Notice for your information.
If you have any questions about my privacy practices, please ask me.
I. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
A. Uses and Disclosures that Do Not Require Written Authorization: I may use and disclose your PHI without your written authorization for certain purposes as described below. The examples in each category are not exhaustive but instead describe the types of uses and disclosures of your PHI that are legally permissible.
- Treatment. I may disclose your PHI to other clinicians involved in your care in order to provide you with integrated treatment. For example, I may discuss your diagnosis and treatment plan with your physician, psychiatrist, another psychologist, or nurse practitioner.
- Payment. I may share PHI with your insurance company if you give me information about your insurance coverage and authorize me to bill for services you do not pay for yourself. If it becomes necessary for me to use collection processes to secure payment for services I have rendered to you, I will disclose only the minimum amount of PHI necessary.
- Health Care Operations. I may use or disclose your PHI to conduct health care operations pertaining to my practice, including contacting you when necessary. For example, I may need to disclose your PHI to my attorney to obtain advice about complying with applicable laws. I will disclose only the minimum amount of PHI necessary.
- Permitted or Required by Law. I may use or disclose your PHI when I am required or permitted to do so by law. For example, I may disclose your PHI to appropriate authorities if I reasonably believe that you are a possible victim of abuse or neglect or the possible victim of other crimes. In addition I may disclose your PHI to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. Other disclosures required by law include the following: health oversight activities by any licensing or legal authority; disclosures to judicial and law enforcement officials in response to a court order or other lawful process; and disclosures for workers’ compensation claims.
B. Uses and Disclosures that Require Your Written Authorization:
- Psychotherapy Notes. I will not disclose the records of our work that I keep separate from the medical record for my personal use, known as psychotherapy notes, except as permitted by law or authorized by you.
- Marketing Communications; Sale of PHI. I will not use your PHI for marketing purposes, nor will I sell it.
- Other Uses and Disclosures. Uses and disclosures other than those described in this Notice will only be made with your written authorization or as required by law. You may revoke any such authorization at any time by providing me with written notification of such revocation.
II. YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI I maintain about you. To exercise any of these rights, please submit your request in writing to me at 8609 Westwood Center Drive, Suite 110 Vienna, VA 22182.
A. Right of Access to Inspect and Copy: You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set.” A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. I may charge a reasonable, cost-based fee for copies. You may also request that a copy of your PHI be provided to another person.
B. Right to Amend: You have the right to request that I amend your PHI. Your request must be in writing, and should explain why the information should be amended. I may deny your request under certain circumstances, and you may then submit a notice of disagreement to be included in your medical record and released when your record is released.
C. Right to an Accounting of Disclosures: You have the right to request an accounting of certain of the disclosures that I make of your PHI. I may charge you a reasonable fee if you request more than one accounting in any 12-month period.
D. Right to Request Restrictions: You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. I am not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, I am required to honor your request for a restriction.
E. Right to Request Confidential Communication: You have the right to request that I communicate with you about health matters in a certain way or at a certain location. I will accommodate reasonable requests. I may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. I will not ask you for an explanation of why you are making the request.
F. Right to Receive Notification of a Breach: If there is a breach of unsecured PHI concerning you, I may be required to notify you of this breach, including what happened and what you can do to protect yourself.
G. Right to a Copy of this Notice: You have the right to a copy of this notice.
H. Right to Ask Questions or File Complaints: If you desire further information about your privacy rights, please discuss your questions with me in person. If you are concerned that I have violated your privacy rights, you have the right to file a complaint in writing with me at 8609 Westwood Center Drive, Suite 110, Vienna, VA 22182. You can also file a complaint by writing the Secretary of Health and Human Services at 200 Independence Avenue, S.W.; Washington, D.C. 20201, or by calling HHS at (202) 619-0257. I will not retaliate against you for filing a complaint.
III. EFFECTIVE DATE AND CHANGES TO THIS NOTICE
A. Effective Date: This Notice is effective on January 1, 2012.
B. Changes to This Notice: I may change the terms of this Notice at any time. If I change this Notice, I may make the new notice terms effective for all PHI that I maintain, including any information created or received prior to issuing the new notice. If I change this Notice, I will post the revised notice on my website at http://capitalprimarygeriatriccare.com and I will furnish you with one at your next appointment.