NOTICE OF PATIENT 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.

If you have any questions or comments about this Notice please contact:
Potomac Podiatry Group, PLLC.
14010 Smoketown Road, Suite 103
Woodbridge, VA 22192

Our Privacy Officer is Patient Account Services, Inc (800)-256-4004

(personal copies available upon request)

Who Does this Notice Apply to?

Potomac Podiatry Group, PLLC, has published this Notice. It applies to everyone who works for Potomac Podiatry Group, PLLC, including our employees, contractors, and volunteers.

Why Do We Publish this Notice?

As medical professionals, we understand that information about you and your health is sensitive and personal. We are also required by law to maintain the privacy of information we gather and use about our patients, and provide them with notices of our legal duties and privacy practices with respect to their information.

While we are committed to the privacy of our patients information, in order to serve them we need to gather, keep and use records of this information. We sometimes also need to share information with other parties. This Notice is intended to let you know how we use and disclose your information.

This Notice is also to let you know about certain legal rights you have with respect to the information we hold about you. You have certain rights to review and copy our records of information about you. You may also request that we amend these records and may ask us to account for certain disclosures we may have made of information about you.

When is This Notice Effective?

We are required to comply with the terms of the Notice while it is in effect. We reserve the right to change the terms of this Notice and make the new terms effective for all information to which this Notice applies. This Notice will be in effect from April 10, 2003, until the date we publish an amended Notice. If we do publish an amended Notice we will notify you at your next visit. We will also publish the amended Notice in our offices and will publish it on our web site if we maintain one.

What Information Does this Notice Cover?

This Notice covers all information in our written or electronic records which concerns you, your health care, and payment for your health care. It also covers information we may have shared with other organizations to help us provide you care, get paid for providing care, or manage some of our administrative operations.

When Can We use or Disclose Information About You?

Treatment:

We may use or disclose information about you for treatment purposes to doctors, nurses, technicians, medical students, or other individuals who work in our practice who are involved in providing you with health care. We may also disclose information about you. To organizations and individuals involved in your care who are outside of our practice, such as consulting physicians laboratories, social workers, and so on.

For example, if we refer you to another physician or a hospital or specialty services, we will provide that physician or hospital with all clinical information, which might be necessary or helpful to help them provide you with the right care. Or, if we need to send a sample of your blood to B laboratory with the information they need to process your blood correctly.

These are only examples, and we may use or disclose information about you to provide you proper treatment in many other ways.

Payment:

We may use or disclose information about you for payment purposes to our clerks and officers involved in billing and claims payment. We may also disclose such information to your health plan or other party financially responsible for your care, or to claims and billing services if necessary

For example, if you are covered by a health plan we cannot get paid for the services we provide you unless we submit information to a claim. This might include detailed clinical information, depending on the kind of plan and claim. This is only an example, and there may be many other ways in which we may use or disclose information about you in connection with payment for your care.

Health care operations:

We may use or disclose information about you for operations in connection with our practice. These activities might include practice quality improvement, training of medical students, insurance underwriting, medical or legal review and business planning or administration of our practice.

For example, we may wish to review the quality of care you receive, in order to help us deliver the best care we can. Or, we may audit our management practices so we can become more efficient. These are only examples, and we may use or disclose information about you for health care operations in many other ways.

• To a public health agency, for purposes such as controlling disease.
• In case of suspected child abuse, to the appropriate governmental authority.
• In other cases of suspected abuse, neglect or domestic violence, to the appropriate governmental authority, with your agreement or if you are incapacitated or it appears necessary to prevent serious harm to you or others.
• To health oversight authorities for regulatory, licensing and other legal purposes.
• In litigation, subject to certain requirements controlling the terms of the disclosure.
• To law enforcement agencies, subject to applicable legal requirements and limitations.
• Worker’s Compensation: In such cases that your treatment is a result of an injury on the job, we may release your information to the appropriate carrier/employer.
• To Funeral Directors/Medical Examiners/Coroners in the event of your death.
• When required by Federal, State, or Local law.
• For medical research purposes, subject to your authorization or approval by an institutional review board.
• If you are in the United State military, national security or intelligence, Foreign Service, to your authorized superiors or other authorized federal officials.

We may contact you for information to support your health care, including appointment reminders, information about alternative treatments, and health-related services, which may be of interest to you. We will routinely contact patients via telephone at home and/or work and unless otherwise requested, may leave messages on the appropriate voice mail or answering service regarding appointments. Please advise us if you do not wish to receive such communications and we will not use or disclose your information for such purposes. If you wish not to receive this kind of communication, you must advise us in writing at our contact address given above.

We may not use or disclose information about for any other purposes with your written authorization.

What Legal Rights Do You Have In Connection With Your Information?

The Law entitles you to:

• Ask us to further restrict our use and disclosure of information about you. We are not required to grant such a request, but if we do we must make sure the restrictions are implemented.
• Receive confidential communications from us, at an alternative address you provide to us.
• Review our records of your information.
• Obtain a copy of all or any part of our records of your information. We may charge you a copying charge of a $10 base fee, $0.50 per page for pages 1-50, then $0.25 for any pages over 50.
• Ask us to amend your records, if you believe that they are incorrect or incomplete. We are not required to make such an amendment. If you request an amendment and we determine we will not make it, you are entitled to have a statement of your disagreement included in your records. If you do include a statement of disagreement in your records, we may include a statement of explanation or response in your records as well.
• Obtain an accounting of all persons to which we have disclosed information about you, for any purpose except your treatment, payment for your treatment, or our health care operations.
• If you believe we have violated your privacy rights, you may forward us a written complaint to our Contact address given above. You may also file a complaint with the Secretary of the United States Department of Health and Human Services. If you do file a complaint we are legally prohibited from retaliating against you.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.