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.
I, Brenda Rozier-Clark, use health information about you for treatment, to obtain payment for treatment, to evaluate the quality of care you receive, and for other administrative and operational purposes. Your health information is contained in a medical record that is the physical property and responsibility of me, Brenda Rozier-Clark. I am required by law to maintain the privacy of health information about you and provide you with this notice of my legal duties and privacy practices with respect to your health information ("Notice of Privacy Practices" or "Notice"). I must abide by the terms of this Notice currently in effect. I reserve the right to change the terms of this Notice, my privacy practices, and to make the new provisions effective for all protected health information I maintain. You may contact me to obtain a revised Notice of Privacy Practices.
Your Health Information Rights: You have the following rights with respect to health information about you. Right to Copy of Notice of Privacy Practices.You have the right to a paper copy of my Notice at any time. Right to Inspect and Copy. You have the right to inspect and/or obtain a copy of the health information about you that I maintain. Your request must be in writing. I will charge you a fee to cover the costs of copying and mailing that are necessary to fulfill your request. In very limited circumstances, I may deny your request. If I deny your request, I will explain my reasons in writing. Right to Amend. If you feel that health information about you that I maintain is inaccurate or incomplete, you have the right to request that I amend the information. You may request an amendment as long as I maintain the information. I may ask that you submit it in writing and include a reason supporting the request. In certain circumstances, I may deny your request. If your request is denied, I will explain my reasons in writing. You may submit a statement explaining why you disagree with my decision to deny your amendment request. I will share your statement when I disclose health information about you that I maintain in certain groups of records. Right to an Accounting of Disclosures. You have the right to request an accounting or detailed listing of certain disclosures of health information about you. The time period covered by the accounting is limited to six years prior to the date of your request. Your request must be in writing. If you request an accounting more often than once every twelve (12) months, I may charge you a fee to cover the costs of preparing the accounting. Right to Request Restrictions. You have the right to request a restriction or limitation on the health information about you that I use or disclose. Your request must be in writing. I am not required to agree to your request. However, I must agree not to disclose health information about you to your health plan if the disclosure is for payment or health care operations and relates to a healthcare item or service which you paid for in full out of pocket. If I agree to your request, I will comply with it unless the information is needed for emergency treatment. I will notify you if I am unable to agree to a requested restriction. Right to Revoke Authorization. You have the right to revoke your authorization to use or disclose health information, except to the extent that action has been taken in reliance upon your authorization. Your request must be in writing Right to Request Alternative Method of Communication. You have the right to request that I communicate with you about medical matters in a certain way or at a certain location. Your request must be in writing. I will accommodate all reasonable requests. Right to Notification of Breach. You have a right to be notified if you are affected by a breach of unsecured health information about you. Right to Opt Out of Fundraising Communications. I may contact you for fundraising purposes. You have the right to opt out to receiving these communications. Complaints: If you believe your privacy rights have been violated, you may complain to the Secretary of the Department of Health and Human Services. You may make a complaint to me by contacting my office address or phone listed below. You will not be retaliated against for filing a complaint.
Uses or Disclosures of Your Health Information That May Be Made Without Your Authorization Treatment. I may use and disclose health information about you to provide you with pharmacy care or other medical treatment or services. For example, information related to your treatment may be communicated with and obtained by a healthcare provider, such as a pharmacist, nurse, or other person providing health services to you, and will be recorded in your medical record. This information is necessary for health care providers to determine what treatment you should receive. Payment. I may disclose health information about you for payment related purposes. For example I may contact your insurer, payor, or other entity, for purposes of receiving payment for treatment and services that you receive or to determine whether the entity will pay for the particular product or service. The billing information may identify you, your diagnosis, and treatment or supplies used in the course of your treatment. Health Care Operations. I may use and disclose health information about you for administrative and operational purposes. For example, members of the risk management or quality improvement teams may use health information about you to assess the care and outcomes in your case and others like it. The results will be used internally to continually improve the quality of care for all patients. Organized Healthcare Arrangement. An organized health care arrangement is a clinically integrated care setting in which individuals typically receive health care from more than one health care provider. I may participate in organized health care arrangements with long-term care facilities, hospice, or other health care facilities in connection with the services I furnish to patients in such settings. Health information may be shared between the participants in the organized health care arrangement for the health care operations of the arrangement. Individuals Involved in Your Care or Payment for Your Care. I may disclose to a family member, other relative, close personal friend or any other person you identify, health information about you directly relevant to that person's involvement in your care or payment related to your care. In addition, I may disclose health information about you to a public or private entity assisting in a disaster relief effort (such as the Red Cross) so that your family can be notified about your condition, status, and location. Business Associates. I provide some services through contracts with business associates, such as accountants, consultants, and attorneys so that they can perform the tasks that we have assigned to them. To protect your health information, we require the business associate to appropriately safeguard health information about you.Appointment Reminders. I may use health information about you to provide you with appointment or prescription reminders. Alternative Treatments. I may use health information about you to provide you with information about alternative treatments or other health-related benefits and services that may be of interest to you. Future Communications. I may communicate with you via newsletters, mailings, or other means regarding treatment options, health-related information, disease-management programs, wellness programs, or other community-based initiatives or activities in which we are participating. Required by Law. I may use and disclose health information about you as required by federal, state, or local law. For example, I may disclose health information for the following purposes: (1) for judicial or administrative proceedings pursuant to legal authority; (2) to report information related to victims of abuse, neglect, or domestic violence; and (3) to assist law enforcement officials in their law enforcement duties. Public Health. I may use or disclose health information about you for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability, or for other health oversight activities. Health Care Oversight.I may use or disclose health information about you to a health oversight agency for oversight activities authorized by law, such as audits, investigations, and inspections.Research. I may use or disclose health information about you to researchers if an institutional review board or privacy board has reviewed and approved the research proposal, and established protocols to ensure the privacy of your health information. Health and Safety. I may use or disclose health information about you to avert a serious threat to your health or safety or any other person pursuant to applicable law.Medical Examiners and Others. I may use or disclose health information about you to medical examiners, coroners, or funeral directors to allow them to perform their lawful duties. If you are an organ or tissue donor, I may disclose health information about you to organizations that help with organ, eye, and tissue donation and transplantation.Food and Drug Administration (FDA). I may use or disclose health information for purposes of notifying the FDA of adverse events with respect to food, supplements, product, and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacements. Information Not Personally Identifiable. I may use or disclose health information about you in ways that do not personally identify you or reveal who you are. Government Functions. I may use or disclose health information about you for specialized government functions, such as protection of public officials, national security and intelligence activities, or reporting to various branches of the armed services. Workers Compensation. I may use or disclose health information about you to comply with laws and regulations related to workers compensation. Correctional Institutions. If you are an inmate of a correctional institution or under the custody of a law enforcement official, I may use or disclosure health information about you. Such health information will be disclosed to the correctional institution or law enforcement official when necessary for the institution to provide you with health care and to protect the health and safety of others.
Uses or Disclosures of Your Health Information Based Upon Your Written Authorization Psychotherapy Notes. I must obtain your written authorization for most uses and disclosures of psychotherapy notes. Marketing. I must obtain your written authorization to use and disclose health information about you for most marketing purposes. Sale of Your Health Information. I must obtain your written authorization for any disclosure of health information about you which constitutes a sale of such health information. Other Uses. Other uses and disclosures of health information about you, not described above, will be made only with your written authorization. You may revoke your authorization, at any time, in writing, except to the extent that we have taken action in reliance on the authorization.
Other Applicable Laws This Notice is provided to you as a requirement of the Health Insurance Portability and Accountability Act ("HIPAA"). There are other laws that may apply and limit my ability to use and disclose health information about you beyond what I am allowed to do under HIPAA. State Laws. I will comply with your state's laws if they provide you with greater rights over your health information or provide for more restrictions on the use or disclosure of your health information. Confidentiality of Alcohol and Drug Abuse Patient Records. The confidentiality of alcohol and drug abuse patient records by me is protected by Federal law and regulations. Generally, I may not say to a person outside my alcohol and drug treatment program that you attend the program, or disclose any information identifying you as an alcohol or drug abuser, unless:(1) You consent in writing;(2) The disclosure is allowed by a court order; or(3) The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation. Violation of the Federal law and regulations by the program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal Regulations. Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities. For more information, see 42 U.S.C 290dd-3 and 42 U.S.C. 290ee-3 for Federal laws and 42 C.F.R Part 2 for Federal regulations.
Contact Information: If you have any questions, requests, or concerns about your related health information rights or my use and disclosure of health information, please contact: Brenda Rozier-Clark,6001 Tower Court, Alexandria, VA. Business telephone: 703-866-9999.