Privacy Notice & Acknowledgement

Privacy Notice & Acknowledgement
NOTICE OF PRIVACY PRACTICES
Virginia Surgery Associates, P.C. 

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.
We are committed to providing you with high quality care and to forming a relationship with you that is built on trust. We understand that information about you is private and we are committed to protecting this information. We protect your privacy and confidentiality rights by creating and putting into practice policies and procedures that allow access to your personal information only for legitimate reasons. 

This notice describes how your health information may be used and disclosed by us, your rights with regard to your health information, and our duties to protect such information. It applies to all records of your care that we maintain. Whether this information is stored in writing, on a computer, or other means, we will keep this information in a safe and secure way that protects your privacy and confidentiality.
I. USES AND DISCLOSURES OF YOUR HEALTH INFORMATION
1. “Protected Health Information” is information that individually identifies you and that we create or get from you or from another health care provider, health plan, your employer, or a health care clearinghouse and that relates to (1) your past, present, or future physical or mental health or conditions, (2) the provision of health care to you, or (3) the past, present, or future payment for your health care.

2. This section describes how we use and disclosure your health information. This section is divided into three components: (1) health information excluding psychotherapy notes and human immunodeficiency virus test ("HIV") results; (2) psychotherapy notes; and (3) HIV test results.

 i. The first discusses how your health information (excluding psychotherapy notes and HIV test results) will be used and disclosed. Below, we have listed the types of uses and disclosures that we may make. Any use or disclosure that is not listed below will only be made with your written authorization. 

ii. The second discusses how we may use and disclose your psychotherapy notes (if we have such information). Frequently, we will be required to obtain your authorization prior to using or disclosing your psychotherapy notes. Below, we discuss the few circumstances under which we can disclose your information without your authorization. 

iii. The third discusses how we may disclose your HIV test results (if we have such information). Like psychotherapy notes, HIV test results are afforded extra protection. There are only a limited number of instances in which the results may be disclosed without your permission. All other disclosures not listed in this section on HIV test results will require your permission.
A. Uses and Disclosures of Your Information (Excluding Psychotherapy Notes and HIV Test Results) 

1. Without Your Authorization
Your health information may be used and disclosed by us for the following purposes without your legal permission. However, prior to making such use or disclosure, we may have to meet certain requirements. 

Treatment, Payment, and Business Purposes. We use and disclose your health information to enable us to provide treatment to you, obtain payment for your care, and manage and administer our practice. For instance, we may use and disclose your health information to your insurer, HMO, or other third party payer to obtain payment for the services that we provide you. As another example, in consulting with a specialist regarding your health care treatment, we use and disclose your information. As a further illustration, we may use and disclose your health information to review the adequacy and quality of the care that you receive. As another example of managing our practice, we may use and disclose your information to create de-identified information to enable us to study our treatment patterns and the care that we provide. 

Appointment Reminders. Your health information may also be used and disclosed by us when we contact you to remind you of an upcoming appointment. 

Business Associates. We may disclose Protected Health Information to our business associates who perform functions on our behalf or provide us with services if the Protected Health Information is necessary for those functions or services. For example, we may use another company to do our billing, or to provide transcription or consulting services for us. All of our business associates are obligated, under contract with us, to protect the privacy and ensure the security of your Protected Health Information. 

To You. We will provide you with your health information upon your request in writing or electronically for copying and inspection and accounting purposes as discussed further in this notice under "Individual Rights." 

Minors. We may disclose the Protected Health Information of minor children to their parents or guardians unless such disclosure is otherwise prohibited by law. 

Secretary. We may provide your health information to the Secretary of the Department of Health and Human Services in order for the Secretary to investigate issues and determine our compliance with federal privacy requirements. 

Required by Law. We will disclose your information when we are required to do so by federal, state, or local law. 

Public Health Activities. We may disclose your information for public health activities. For example, we may disclose your health information to a public health agency to assist in an investigation of food poisoning. As another example, we may disclose your health information to enable a public health agency to study diseases (e.g., cancer registries) or deaths of public health importance. 

Health Oversight Activities. We may disclose your information for health oversight activities. For example, a health oversight activity may include the disclosure of information in the course of an investigation of a provider’s conduct to a state licensing board official. 

Cadaveric Organ, Eye or Tissue Donation. We may disclose your information if you are an organ, eye or tissue donor so that we can assist entities with donations and transplants. 

To Avert a Serious Threat to Health or Safety. We may use and disclose your information if it is necessary to avert a serious threat to the health or safety of yourself or others or to assist law enforcement authorities in identifying or apprehending an individual. 

Coroners, Medical Examiners, and Funeral Directors. We may disclose your information to coroners, medical examiners, and funeral directors to assist them in identifying a deceased person, determining the cause of death, or other duties required for them by law. 

Research. We may disclose your information for medical or health-related research. However, this type of disclosure, similar to some others in this category, will require that the recipient (i.e., researcher) ensures that your information will be protected. 

Abuse, Neglect, or Domestic Violence. We may report your health information to government authorities if we have a reasonable belief that a situation involves abuse, neglect or domestic violence and the patient agrees or we are required or authorized by law to make that disclosure. 

Judicial and Administrative Proceedings. We may release your health information for judicial and administrative proceedings. Such proceedings would include responses to court orders or subpoenas. Like most other disclosures in this category, certain requirements would need to be met prior to our disclosure to ensure that your privacy is protected. 

Workers’ Compensation. We may release your health information for the purpose of processing and adjudicating workers’ compensation claims. 

For Specialized Government Functions. We may disclose your information if you are a member of the military as required by military authorities. This would also include releases for foreign military personnel. Additionally, we may disclose your information to federal officials for national security reasons as authorized by law. 

Law Enforcement Purposes. We may disclose your information for law enforcement purposes if requested by a law enforcement official. For example, we may disclose your information if it would assist the law enforcement agent in locating a material witness to a crime. 

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose Protected Health Information to the correctional institution or law enforcement official if the disclosure is necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3)for the safety and security of the correctional institution. 

Planning of Health Care Services. We may disclose your health information to assist local health partnerships established by law to plan and ensure health care services. For example, we may provide your information to assist the partnerships in identifying common diseases in a certain community and providing treatment to improve the health of the community. 

Quality and Cost of Services. We may provide your information to a nonprofit organization established by law for the purpose of ensuring quality services at reasonable prices. Such a disclosure may be to assist that nonprofit organization in determining the relative quality of services provided by one physician as compared to his peers. 

Data Breach Notification Purposes. We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.
2. Opt
Out Individuals Involved in Your Care or Payment for Your 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. 

Disaster Relief. Unless you object we may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practicably can do so. 

Fundraising. Although we may use your health information when we contact you to raise money, we do not engage in fundraising at this time. You have the right to opt out of receiving such communications. Most uses of and disclosure of PHI for marketing, fundraising and sales purposes require your authorization. If you have any questions, please call Timothy Shaver, MD at 703-359-8640.
3. All Other Uses And Disclosures Require Authorization
As stated previously, any use or disclosure that is not listed above will only be made with your written authorization. Once you execute an authorization, you have the right to revoke that authorization in writing to prevent future use and disclosure of your health information. However, you may not revoke the authorization for the purpose of the use or disclosure to the extent that the recipient of your health information has already taken action and relied upon it.
B. Uses and Disclosures of Psychotherapy Notes
We may use and disclose your psychotherapy notes as stated below. However, all other uses and disclosures of your psychotherapy notes will require us to obtain an authorization from you. 

Limited Treatment, Payment, and Business Purposes. We may use or disclose your psychotherapy notes if (1) we created the psychotherapy notes and we are using or disclosing them for your treatment purposes; (2) such use or disclosure is for the purpose of providing training to students, trainees, or practitioners under our supervision; or (3) such use or disclosure is for the purpose of defending ourselves or our practice against a legal action or other proceeding brought by you. 

Secretary. We may provide your psychotherapy notes to the Secretary of the Department of Health and Human Services in order for the Secretary to investigate us and determine our compliance with federal privacy requirements. 

Required by Law. We will disclose your information when we are required to do so by federal, state, or local law. 

To You. Depending upon your specific circumstances, we may provide your psychotherapy notes to you for inspection and copying purposes upon your request. 

Health Oversight Activities. We may disclose your psychotherapy notes for health oversight activities if we are the creators of the notes and they are needed to investigate our conduct. 

To Avert a Serious Threat to Health or Safety. We may use and disclose your psychotherapy notes if it is necessary to avert a serious threat to the health or safety of yourself or others. 

Coroners and Medical Examiners. We may disclose your psychotherapy notes to coroners or medical examiners to assist them in identifying a deceased person, determining cause of death, or other duties required for them by law.
C. Use and Disclosure of HIV Test Results
As stated previously, HIV test results may only be disclosed for a limited number of reasons without your legal permission. We will only disclose your results for the reasons listed below without your legal permission. All other disclosures will require your legal permission. 

Departments of Health. We are legally required to report all HIV test results to the VA Department of Health. Additionally, we may report this information to other departments of health for the purpose of disease surveillance and investigation. 

Consultation, Care or Treatment. We may provide your test results to other health care providers to assist them in providing care and treatment to you. For example, we may provide your HIV test results to a physician who is treating you for a condition related to HIV. We may also provide your test results to other health care providers caring for your baby. 

Research. We may provide your test results to researchers for use as statistical data only. However, such researchers would be required to meet other conditions to ensure that your HIV test results remain confidential. 

Administrative or Judicial Proceedings. We may disclose the results of your HIV test if required by a court order. 

Required by Law. We may disclose your HIV test results to any person who is authorized by law to receive such information. For example, if during a procedure, a physician is exposed to your blood, we may disclose the fact that you are HIV positive to him. 

Tissues and Organ Donation. We may disclose your status to any facility that procures processes, distributes or uses blood, other body fluids, tissues or organs.
II. YOUR RIGHTS
You have the following rights, subject to certain limitations, regarding your Protected Health Information: 

Right to Inspect and Copy. You have the right to inspect and copy Protected Health Information that may be used to make decisions about your care or payment for your care. We have up to 30 days to make your Protected Health Information available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review. 

Right to a Summary or Explanation. We can also provide you with a summary of your Protected Health Information, rather than the entire record, or we can provide you with an explanation of the Protected Health Information which has been provided to you, so long as you agree to this alternative form and pay the associated fees. 

Right to an Electronic Copy of Electronic Medical Records. If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record. 

Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured Protected Health Information. 

Right to Request Amendments. If you feel that the Protected Health Information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for us. A request for amendment must be made in writing to the Privacy Officer at the address provided at the end of this Notice and it must tell us the reason for your request. In certain cases, we may deny your request for an amendment. If we deny your request for an amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. 

Right to an Accounting of Disclosures. You have the right to ask for an “accounting of disclosures,” which is a list of the disclosures we made of your Protected Health Information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice. It excludes disclosures we may have made to you, to family members or friends involved in your care, or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions and limitations. Additionally, limitations are different for electronic health records. The first accounting of disclosures you request within any 12-month period will be free. For additional requests within the same period, we may charge you for the reasonable costs of providing the accounting. We will tell you what the costs are, and you may choose to withdraw or modify your request before the costs are incurred. 

Right to Request Restrictions. You have the right to request a restriction or limitation on the Protected Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Protected Health Information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. To request a restriction on who may have access to your Protected Health Information, you must submit a written request to the Privacy Officer. 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, unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If we do agree to the requested restriction, we may not use or disclose your Protected Health Information in violation of that restriction unless it is needed to provide emergency treatment. 

Out-of-Pocket-Payments. If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request. 

Right to Request Confidential Communications. You have the right to request that we communicate with you only in certain ways to preserve your privacy. For example, you may request that we contact you by mail at a specific address or call you only at your work number. You must make any such request in writing and you must specify how or where we are to contact you. We will accommodate all reasonable requests. We will not ask you the reason for your request. 

Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time.
III. OUR RESPONSIBILITIES
We are required by law to maintain the privacy of your health information and to notify you of a security breach, in all circumstances except when we conduct a risk assessment and establish there is a low probability of compromise of your PHI. We are also required provide you with notice of our legal duties and privacy practices with respect to your health information. We must abide by the terms of the Notice currently in effect. 

However, we reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all health information that we maintain. We will provide you with a revised Notice upon request. We may change our privacy policies at any time. However, before we make a significant change in our privacy policies, we will change our Notice and post the new Notice. The Privacy Notice will be posted in the waiting area. You can also request a copy of our Notice at any time by contacting us as discussed below.
IV. COMPLAINTS
You may file a complaint with us or with the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated. 

To file a complaint with the Secretary, mail it to: Secretary of the U.S. Department of Health and Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201. Call (202) 619-0257 (or toll free (877) 696-6775) or go to the website of the Office for Civil Rights, www.hhs.gov/ocr/hipaa/, for more information. There will be no retaliation against you for filing a complaint. 

To file a complaint with us, contact Timothy Shaver, MD at 3620 Joseph Siewick Drive Suite 406, Fairfax, VA 22033. All complaints must be made in writing and should be submitted within 180 days of when you knew or should have known of the suspected violation. Virginia Surgery Associates, PC will not punish or retaliate against you for filing any complaint.
V. CONTACT US
If you have additional questions, please contact our Privacy Officer, Timothy Shaver, MD by phone at 703-359-8640. This notice of privacy practices is effective on June 24, 2013.