NOTICE of PRIVACY PRACTICES
EFFECTIVE: APRIL 14, 2003
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
Our office takes the privacy of your health information seriously. We are required by law to maintain that privacy and to provide you with this Notice of Privacy Practices. This Notice tells you about our duties and practices regarding your information. We are required to abide by the terms of this Notice that are currently in effect. We reserve the right to revise this Notice.
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
The following categories describe different ways that we may use and disclose your health information. For each category. an explanation and some examples are given. Not every use or disclosure in a category will be listed. However, the ways we are permitted to use and disclose information will fall within one of the categories.
- For Treatment - We may use health information about you to provide you with
treatment, health care, or other related services. We may disclose your health
information to doctors, nurses, aides, technicians or other employees who are involved
in taking care of you. Also, we may use or disclose your health information to manage
or coordinate your treatment, health care, or other related services.
- For Payment - We may use and disclose your health information to bill and collect for
the treatment and services we provide to you. We may send your health information to
an insurance company or other third party for payment purposes including to a
- For Health Care Operations - We may use and disclose your health information for
health care operations. These uses and disclosures are necessary to operate our
practice, to make sure you receive competent, quality health care, and to maintain and
improve the quality of health care we provide.
- As Required by Law - We will disclose your health information when required to do so
by federal, state, or local law.
- For Public Health Purposes - We will disclose your health information for public
health activities. While there may be others, these activities generally include:
- Preventing or controlling disease, injury, or disability;
- Reporting deaths;
- Reporting defective medical devises or problems with medications;
- Notifying people of recalls of products or medications they may be using;
- Notifying a person who may have been exposed to a disease or may be at risk
for contracting or spreading a disease or condition
- About Victims of Abuse - We may disclose your health information to notify the appropriate government authority if we believe an individual has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
- Health Oversight Activities - We may disclose your health information to a health oversight agency for activities authorized by law. These oversight activities might include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government benefit programs, and compliance with civil rights laws.
- Judicial Purposes - We may disclose your health information in response to a court or administrative order. We may also disclose your health information in response to a subpoena, discovery request, or other lawful process by someone else involved in a dispute, but only if efforts have been made to tell you about the request, in which you were given an opportunity to object to the request, or to obtain an order protecting the information requested.
- Law Enforcement - We may release health information if asked to do so by a law enforcement official, if such disclosure is:
- Required by law,
- In response to a court order, subpoena, warrant, summons, or similar purposes
- 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; or
- In emergency circumstances to report a crime; the location of the crime or
victims; or identity, description or location of person who committed the crime
- Coroners, Medical Examiners and Funeral Directors - In certain circumstances, we may disclose 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 health information about individuals to funeral directors as necessary to carry out their duties.
- Organ and Tissue Donation - We may disclose your health information to organizations that handle organ procurement, or eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation
- Research - Under certain circumstances, we may disclose 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. All research projects are subject to a special approval process. Before we
use or disclose health information for research, the project will have been approved
through this research approval process.
- Military and Veterans - if you are a member of the armed forces, we may release your
health information as required by military command authorities. We may also release
health information about foreign military personnel to the appropriate foreign military
- National Security and Intelligence Activities - We may release your health
information to authorized federal officials for lawful intelligence, counterintelligence,
and other national security activities authorized by law.
- Workers Compensation - We may disclose your health information as authorized by
and to the extent necessary to comply with workers' compensation laws or laws relating
to similar programs.
- Appointment Reminders - We may use and disclose your health information to
provide appointment reminders. If you do not wish us to contact you about appointment
reminders, you must notify us in writing.
- Individuals Involved in Your Care or Payment for Your Care - We may release
health information about you to a family member, other relative, or any other person
identified by you who is involved in your health care. We may also give information to
someone who helps pay for your care. We may also tell your condition to your family,
friends, personal representative or other person responsible for your health care.
- Third Party - We may disclose your health information to third parties with whom we
contract to perform services on our behalf. If we disclose your information to these
entities, we will have an agreement by them to safeguard your information.
OTHER USES OF HEALTH INFORMATION
Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you provide us authorization to use or disclose your health information, you may revoke or withdraw that authorization, in writing, at any time. If you revoke that authorization, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made under the authorization, and that we are required to retain our records of the care that we provided you.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
- Right to Request Restrictions - You have the right to request a restriction or limitation
on the health information we use or disclose about you for treatment, payment, or other
health care operations. You also have the right to request a limit on health information
we disclose about you to someone involved in your care or the payment for your care.
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 our office as follows:
Harold E. Bondy, M.D., 611 South Carlin Springs Rd., Suite 203, Arlington, VA 22204.
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.
- Right to Request Confidential Communication - You have the right to request that
we communicate with you or your responsible party about your health care in an
alternative way or at a certain location.
- Right to Inspect and Have Copied - You have the right to inspect and have
photocopied information that may be used to make decisions about your care.
To inspect and have photocopied health information that may be used to make
decisions about you, you can submit your request in writing to our office as follows:
Harold E. Bondy, M.D., 611 South Carlin Springs Rd., Suite 203, Arlington, VA 22204.
If you request a copy of the information, we will charge a fee for record retrieval, costs
of copying, mailing and other supplies associated with your request.
- Right to Amend - You have the right to ask us to amend your health and/or billing
information for as long as the information is kept by our office.
To request an amendment, your must send your request in writing to: Harold E. Bondy,
M.D., 611 South Carlin Springs Rd., Suite 203, Arlington, VA 22204. 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, if it does not include
a reason to support the request, or 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 health information kept by or for us;
- Is not part of the information which you would be allowed to inspect and copy; or
- Is accurate and complete.
- Right to Accounting of Disclosures - You have the right to request a list of certain
disclosures that we have made of your health information. To request a list of
disclosures, you must send your request in writing to: Harold E. Bondy, M.D., 611
South Carlin Springs Rd., Arlington; VA 22204. Your request must state a time period
which may not be longer than 6 years and may not include dates before April 14, 2003.
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.
CHANGES TO THIS NOTICE
We reserve the right to change this Notice. We reserve the right to make the revised Notice
effective for health information we already have about you as well as any information we
receive in the future. We will give you a copy of this Notice on your first encounter with this
office that occurs on or after April 14, 2003.
If you believe your privacy rights have been violated, you may file a complaint with our office
or with the Department of Health and Human Services. To file a complaint with our office,
contact our Office Manager at 703.671.7240. All complaints must be submitted in writing.
The health care services provided to you by this office will not be affected in any way for
filing a complaint.