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1020 First Colonial Road
Virginia Beach, VA 23454
Mon-Fri, 9:00 a.m. - 5:00 p.m.

Telephone (757) 481-2313


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Virginia Beach Surgery

NOTICE OF PRIVACY PRACTICES

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.

The effective date of this Privacy Notice is April 14, 2003. The latest revision of this Privacy Notice is January 11, 2006.

This Notice of Privacy Practices is being provided to you as a requirement of the privacy regulations issued under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This notice describes how Southern Surgical Associates (SSA) may use and disclose medical information/personal health information about you to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control personal health information about you. Your personal health information (i.e., “protected health information” for purposes of HIPAA) is information about you, including demographic information that may identify you and that relates to your past, present or future physical or mental health condition. We are required by law to maintain the privacy of your personal health information, and we must abide by the terms of this notice.

In this notice we provide descriptions of the different ways we may use and disclose your personal health information. In some cases, an example is provided to describe the types of uses and disclosures of your personal health information that may be made by SSA. However, these examples are not intended to be inclusive of all the ways we may use your personal health information.

ACKNOWLEDGMENT OF RECEIPT OF THIS PRIVACY NOTICE

You are receiving our current Privacy Notice and are asked to sign an acknowledgment that you have received it. You may provide the signed acknowledgment by: signing the last page of this Privacy Notice and returning it to reception desk or a nurse, physician or other staff member, or my mailing it to the following address: 1020 First Colonial Road, Virginia Beach, VA 23454, Attention: Privacy Officer.

If, after April 14, 2003, your initial contact with our office is through electronic mail, you will be asked to acknowledge receipt of this Privacy Notice by replying to our electronic message that contains the Privacy Notice and typing the following in your reply message: "I acknowledge receipt of the Privacy Notice", and including the date and your name.

HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION (PHI) ABOUT YOU

The following categories describe different ways that we use and disclose personal health information about you. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment. We may use and disclose your personal health information as reasonably necessary to provide for your treatment. We do not need to obtain your permission, written or otherwise, for us to do this. We may disclose personal health information about you to doctors, nurses, technicians or other healthcare personnel who are involved in taking care of you. For example, a doctor that provides anesthesia during surgery needs to know your health history. Nurses at the hospital need to know if you have diabetes in order to provide the appropriate medications during your hospital stay.

For Payment. We may use and disclose personal health information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about a procedure performed in our office so your health plan will pay us or reimburse you for the procedure. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations. We may use and disclose personal health information about you for healthcare operations. These uses and disclosures are necessary to run our office and make sure that all individuals receive quality care.

For example, we may use personal health information as follows:

· to review our treatment and services · for compliance review activities

·· to evaluate the performance of our staff in caring for you · for training of medical professionals

Day-to-day tasks that are required to ensure effective care include the following:

· use of sign–in sheets at our front desks

· appointment reminders by phone and mail-

Appointment reminders will be mailed to the address you have provided on our registration form. These may include your name; the name of the physician you are scheduled to see; our practice name; and reminders for referrals, co-payments, diagnostic studies such as films and lab reports, and copies of medical records.

· telephone contact to discuss treatment, test results, and financial arrangements

· leaving a message on your answering machine regarding your appointment or asking you to contact us regarding test results or other clinical matters-

Messages may include your name; the name of the physician you are scheduled to see; our practice name; and reminders for referrals, co-payments, diagnostic studies such as films and lab reports, and copies of medical records.

·· calling you by name in the waiting room when your doctor is ready to see you at the time of your appointment

As another part of health care operations, we may use and disclose personal health information about you to our “business associates”. Our business associates, such as transcription services, collection agencies, and call-answering services, perform services on behalf of our Practice. Whenever an arrangement between our Practice and a business associate involves the use or disclosure of personal health information about you, we will have a written contract with that business associate that will require such business associate to agree to protect the privacy of your personal health information.

Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may release personal health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you are in a hospital. You may request that we restrict communications regarding your personal health information to these individuals. However, you must notify us if there is a family member or friend to whom you do not wish us to relay your personal health information.

Research. Under certain circumstances, we may use and disclose personal health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of personal health information, trying to balance the research needs with individuals' need for privacy of their personal health information. Before we use or disclose personal health information for research, the project will have been approved through this research approval process, but we may, however, disclose personal health information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the personal health information they review does not leave our office. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care.

As Required By Law. We will disclose personal health information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose personal health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Organ and Tissue Donation. If you are an organ donor, we may release personal health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, we may release personal health information about you as required by military command authorities. We may also release personal health information about foreign military personnel to the appropriate foreign military authority.

Workers' Compensation. We may release personal health information about you for workers' compensation or similar programs. These programs provide benefits for work‑related injuries or illness.

Public Health Risks. We may disclose personal health information about you for public health activities. These activities generally include the following:

· to prevent or control disease, injury or disability;

· to report births and deaths;

· to report child abuse or neglect;

· to report reactions to medications or problems with products;

· to notify people of recalls of products they may be using;

· to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;

·· to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence.

Health Oversight Activities. We may disclose personal health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose personal health information about you in response to a court or administrative order. We may also disclose personal health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release personal health information if asked to do so by a law enforcement official:

· In response to a court order, subpoena, warrant, summons or similar process;

· To identify or locate a suspect, fugitive, material witness, or missing person;

· About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;

· About a death we believe may be the result of criminal conduct;

· About criminal conduct at our office; and

·· In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. We may release personal health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release personal health information about an individual to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities. We may release personal health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others. We may disclose personal health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release personal health information about you to the correctional institution or law enforcement official. This release would be 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.

Pursuant to an Authorization. We will require a signed authorization form before we disclose your personal health information to a third party for reasons other than those listed above. We will retain a copy of any signed authorization you give us that is attached to a request to us for your personal health information. We will also keep a record of when, to whom and what we provided in response to the request for disclosure. If you have signed an authorization for use to use or disclose your personal health information, and decide you want to revoke the authorization, you have the right to revoke it. You must revoke the specific authorization in writing and deliver it to the Privacy Officer at 1020 First Colonial Road, Virginia Beach VA 23454 before your revocation is effective. Once we receive the revocation, or have actual knowledge that you have revoked the authorization, we will make a note of it to assure that we do not make future disclosures pursuant to your original authorization.

YOUR RIGHTS REGARDING PERSONAL HEALTH INFORMATION ABOUT YOU

You have the following rights regarding PERSONAL HEALTH INFORMATION we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy personal health information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.

To inspect and copy personal health information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer at 1020 First Colonial Road, Virginia Beach VA 23454. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. Patient records shall be maintained a minimum of six years following the last patient encounter or in the case of minors, six years following the last patient encounter or reaching the age of eighteen, whichever is later.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to personal health information, you may request that the denial be reviewed. Another licensed health care professional chosen by us will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend. If you feel that personal health information we have about you 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 the Practice.

To request an amendment, your request must be made in writing and submitted to the Privacy Officer at 1020 First Colonial Road, Virginia Beach VA 23454. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

· Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;

· Is not part of the personal health information kept by or for us;

· Is not part of the information which you would be permitted to inspect and copy; or

·· Is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an accounting of certain disclosures of your personal health information that we have made. (We do not have to provide an accounting of disclosures made for treatment, payment or healthcare operations, or pursuant to a signed authorization or where you did not orally deny authorization, or of certain disclosures required by law.)

To request this list or accounting of disclosures, you must submit your request in writing to the Privacy Officer at 1020 First Colonial Road, Virginia Beach VA 23454. Your request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the personal health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the personal 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. For example, you could ask that we not use or disclose information about a procedure you had.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing to the Privacy Officer at 1020 First Colonial Road, Virginia Beach VA 23454. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to the Privacy Officer at 1020 First Colonial Road, Virginia Beach VA 23454. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

You may obtain a copy of this notice at our website, www.vabeachsurgery.com.

To obtain a paper copy of this notice, send your written request to the Privacy Officer at 1020 First Colonial Road, Virginia Beach VA 23454.

Our current Privacy Notice will also be posted in our offices for you to review.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us. To file a complaint with us, contact the Privacy Officer at 757-481-2313. All complaints must be submitted in writing to the Privacy Officer at 1020 First Colonial Road, Virginia Beach VA 23454.

You also have the right to complain to the Secretary of the Department of Health and Human Services by contacting him/her at: Region III, Office for Civil Rights, US Department of Health and Human Services, 150 S. Independence Mall West, Suite 372, Public Ledger Building, Philadelphia, PA 19106-9111.

You will not be penalized for filing a complaint.