Please send at least 3 business days or more prior to your appointment and be sure to bring a copy with you in case of electronic failure. If you do not have access to a fax machine or scanner it is fine to bring the forms with you to your appointment.
THIS NOTICE DESCRIBES HOW YOUR INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.
At Physicians To Women, Inc., we are committed to treating and using protected health information responsibly. This Notice of Health Information Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective September 1, 2002, and applies to all protected health information as defined by federal regulations.
Each time you visit Physicians To Women, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:
Although your health record is the physical properly of Physicians To Women, Inc., the information belongs to you. You have the right to: (Fees may apply to cover the cost of copying, mailing, or other supplies associated with your request.)
Physicians To Women is required to:
We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue to use or disclose your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.
If you have questions and would like additional information, you may contact the practice’s Privacy Officer, Thomas McDonald, (540) 982-8881. If you believe your privacy rights have been violated, you can file a complaint with the practice’s Privacy Officer, or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be not retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights. The address for the OCR is listed below: Office for Civil Rights U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Room 509F, HHH Building Washington, D.C. 20201
We will use your health information for treatment. For example: Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your health care team. Members of your health care team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment.
We will also provide your physician or a subsequent health care provider with copies of various reports that should assist him or her in treating you once you’re discharged from this hospital. In addition, we may use a sign-in sheet at the registration desk. We may also call you by name in the registration area when your physician is ready to see you or to complete the registration process.
We will use your health information for payment. For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
We will use your health information for regular health operations. For example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.
Business associates: There are some services provided in our organization through contacts with business associates. Examples include physician services in the emergency department, radiology, and certain laboratory tests. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.
Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.
Communication with family: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.
Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
Funeral directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties.
Organ procurement organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Marketing: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Fund raising: We may contact you as part of a fund-raising effort. Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
Public health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Correctional institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.
Law enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the facility. In leaving a message on an answering machine, we will only leave our name, and the appointment’s time and date. We may disclose your medical information to a health care oversight agency for oversight activities authorized by law, including audits, investigations, inspections, licensure or disciplinary actions, administrative and/or legal proceedings. We may use or disclose your medical information to appropriate persons to prevent or lessen a serious threat to the health of safety of another person or the public. We may use and/or disclose your medical information as may otherwise be required under federal or state law, including but not limited to disclosures under the Virginia Health Records Privacy act.