THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY. DR. VIRTS CONSIDERS THE PRIVACY OF YOUR HEALTH INFORMATION OF PARAMOUNT IMPORTANCE.
YOUR PROVIDER’S LEGAL DUTY
As a recipient of health care services, you have certain rights. Dr. Virts is required by law to maintain the privacy of your health information, to give you this written Notice about her privacy practices and legal duties, and your rights concerning your health information. She will follow the privacy practices that are described in this Notice while it is in effect. Dr. Virts reserves the right to change the privacy practices and the terms of this Notice at any time. Before making a significant change in privacy practices, she will make reasonable efforts to change this Notice and make the new Notice available upon request. You may request a copy of the Notice at any time. For more information about her privacy practices, or for additional copies of this Notice, please contact her using the above contact information.
USE AND DISCLOSURES OF HEALTH INFORMATION
Dr. Virts will use and disclose health information about you only as necessary for treatment, payment, and healthcare operations. For example:
Treatment: She may use or disclose your health information to a physician or other healthcare provider involved in your treatment.
Payment: She may use and disclose your health information to obtain payment for services she provides to you.
Health Care Operations: She may use and disclose your health information in connection with her health care operations, including quality assessment and improvement activities.
Your Authorization: In addition to using your health information for treatment, payment, or health care operations, you may give Dr. Virts written authorization to use your health information or to disclose it to anyone for any purpose. If you give Dr. Virts a written authorization, you may revoke it in writing at any time, although such revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give Dr. Virts written authorization, she will not use or intentionally disclose your health information for any reason except those described in this Notice.
To Your Family and Friends: Dr. Virts must disclose your health information to you, as described in the Patient Rights section of this Notice. She may disclose your health information to a family member, friend, or other person to the extent necessary to help with your health care or with payment for your health care, but only if you agree in writing that she may do so.
Persons Involved In Your Care: Dr. Virts may use or disclose health information to notify or assist in the notification of (including identifying or locating) a family member, your personal representative, or another person responsible for your care, concerning your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, she will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, she will disclose health information based on a determination using her professional judgment disclosing only health information that is directly relevant to the person’s involvement in your health care.
Marketing Health-Related Services: Dr. Virts will not use your health information for marketing communications.
Required by Law: Dr. Virts may use or disclose your health information when she is required to do so by law.
Abuse or Neglect: Dr. Virts may disclose your health information to appropriate authorities if she reasonably believes that you may be a victim of abuse, neglect, or domestic violence or the possible victim of other crimes. She may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: Dr. Virts may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. She may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. She may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmates or patients under certain circumstances.
Appointment Reminders: Dr. Virts may use or disclose your health information to provide you with reminders about your appointments or check-ins/follow-ups about missed appointments.
Access: You have the right to review or obtain copies of your health information, with limited exceptions. You may request copies in a format other than photocopies. Dr. Virts will use the format you request unless she cannot practically do so. You must make a request in writing to obtain access to your health information. You will be charged a reasonable copying fee and actual postage and supply costs for your protected health information. If you request additional copies, you will be charged a fee for copying and postage.
Disclosure Accounting: You have the right to receive a list of instances in which Dr. Virts disclosed your health information for purposes other than treatment, payment, health care operations and certain other activities, for the last 6 years. She will provide such a list at no charge upon your request once in any 12-month period. She reserves the right to charge you for requests in excess of one per 12-month period.
Restrictions: You have the right to request that Dr. Virts place additional restrictions on her use or disclosure of your health information. She is not required to agree to these additional restrictions, but if she does, she will abide by the agreement (except in an emergency).
Alternative Communication: You have the right to request that Dr. Virts communicates with you about your health information by alternative means or to alternative locations. You must make your request in writing. Your request must specify the alternative means or location and provide a satisfactory explanation how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that Dr. Virts amend your health information. Any such request must be in writing and explain why the information should be amended. Dr. Virts is not obligated to make the requested amendments, but she will give each request careful consideration.
QUESTIONS AND COMPLAINTS
To learn more about Dr. Virts’ privacy practices or have questions or concerns, please contact Dr. Virts. If you are concerned that she may have violated your privacy rights, or you disagree with a decision she made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have her communicate with you by alternative means or at alternative locations, you may contact Dr. Virts. You also may submit a written complaint to the U.S. Department of Health and Human Services. She will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. Dr. Virts supports your right to the privacy of your health information and will not retaliate in any way if you choose to file a complaint with her or with the U.S. Department of Health and Human Services.
Acknowledgement: “By signing below, I hereby acknowledge that I have read and understand this Notice of Privacy Practices.”
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