Notice of Privacy Practices for Protected Health Information

This Notice describes how medical information about you may be used and disclosed as well as how you may access this information. Please review it carefully!

With your consent, the practice is permitted by law to use and disclose your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain through providing our services to you. This information may include: documenting symptoms, examination and test results, diagnoses, treatment, applying for future care or treatment, and billing documents for those services.

Example of Uses of your Health Information for Treatment Purposes:

A dental assistant obtains health information about you and records it in a health record. During your course of treatment, the dentists determines a need to consult with another specialist. The dentist may share information with such specialist and obtain input.

Example of Uses of your Health Information for Payment Purposes:

We submit a request for payment to your health insurance company. The health insurance company requests information from our office regarding medical care given. We will provide information to them about you and the care given.

Example of Uses of your Health Information for Health Care Purposes:

We obtain services from our insurers or other business associates such as quality assessment or improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services.

Your Health Information Rights:

The health record we maintain and pulled records are the physical property of the practice; however, information

within those records belongs to you. You have a right to:

  • Request, in writing delivered to our office, a restriction on certain uses and disclosures of your health information. We are not required to grant the request, but we will comply with any granted requests
  • Request, in writing delivered to our office, to inspect and copy your health and billing records
  • Appeal a denial of access to your protected health information except in certain circumstances
  • Request, in writing delivered to our office, to have your health care record be amended to correct incomplete or incorrect information
  • File a statement of disagreement if your amendment is denied, and require the request for amendment and denial to be attached in all future disclosures of your protected health information
  • Obtain an accounting of disclosures of your health information as required to be maintained by law through a written request delivered to our office. An accounting will NOT include: internal uses of information for treatment, payment, or operations, disclosures made to you/at your request, or disclosures made to family members/friends while providing care to you
  • Request, in writing delivered to our office, that communication of your health information be made by alternative means or at an alternative location
  • Revoke previously made authorizations to use or disclose information except to the extent that information or action has already been taken by delivering a written revocation to our office

To exercise any of the rights stated above, please contact our office at (703) 729-7447. We will provide you with assistance on the steps needed to exercise your rights.

You have the right to review this Notice before authorizing use and disclosure of your protected health information for treatment, payment, and health care operations.

Our Responsibilities:

The practice is required to:

  • Maintain the privacy of your health information as required by law
  • Provide you with a Notice of our duties and privacy practices regarding the information we collect and maintain about you
  • Abide by the terms of this Notice
  • Accommodate your reasonable requests regarding methods to communicate health information with you

We reserve the right to amend, change, or eliminate provisions in our privacy and access practices as well as enacting new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to call and request a newly revised copy of the Notice or you may visit our office to pick up a copy.

Other Disclosures and Uses:

Notification

Unless you object, we may use or disclose your protected health information to notify a family member, personal representative, or other person responsible for your care about your location, general condition, or death.

Communication with Family

Using our best judgement, we may disclose to a family member, relative, close friend, or any other person you identify health information relevant to the person’s involvement in your care or payment for such care if not objected by you or in an emergency.

Other Uses

Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization. You may revoke the authorization as previously noted.

To Request Information or File a Complaint:

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact our office at (703) 729-7447.

Additionally, if you believe your privacy rights have been violated, you may file a written compliant at our office or delivered to our office. You may also file a complaint by mailing or emailing it to the Secretary of Health and Human Services.

  • We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from our practice
  • We cannot, and will not, retaliate against you for filing a complaint with the Secretary
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