Patient Privacy
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Northern Virginia Family Practice Associates
 4401 Ford Avenue, Suite 250
Alexandria, Virginia 22302
703 379-8879

Notice of Privacy Practices

As required by the Privacy Regulations Created as a Result of the Health Insurance

Portability and Accountability Act of 1996 (HIPAA)

This Notice describes how medical information about you (as a patient of this practice may be used and disclosed, and how your can get access to this information.

PLEASE REVIEW THIS NOTICE CAREFULLY.

    I. WHO WE ARE
    This Notice describes the privacy practices of Northern Virginia Family Practice Associates, their physicians, nurses, staff, volunteers and other personnel. It applies to services furnished to you at our office.

    II. OUR COMMITMENT TO YOUR PRIVACY
    We are required by law to maintain the privacy of your health information (“Protected Health Information” or “PHI”) and to provide you with this notice of our legal duties and privacy practices with respect to your Protected Health Information. When we use or disclose your Protected Health Information, we are required to abide by the terms of this notice.

    III. PERMISSIBLE USES AND DISCLOSURES WITHOUT YOUR WRITTEN AUTHORIZATION

  1. 1. For Treatment, Payment and Health Care Operations: We may use and disclose PHI in order to treat you, obtain payment for services provided to you, and conduct our “health care operations” as detailed below:
    • Treatment. We may use and disclose your PHI to provide treatment and other services to you--for example, to diagnose and treat your injury or illness, laboratory tests, and/or write a prescription. We may also disclose PHI to other providers involved in your treatment.
    • Payment. We may use and disclose your PHI to obtain payment for services that we provide to you--for example, disclosures to claim and obtain payment from your health insurer, HMO, or third parties that may be responsible for such costs to verify that they will pay for your health care.
    • Health Care Operations. We may use and disclose your PHI for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. We may use and disclose your PHI to contact you and remind you of an appointment. We may disclose your PHI to other providers and entities to assist in their health care operations.
    2. Disclosure to Relatives, Close Friends and Other Caregivers: We may use or disclose your PHI to a family member, other relative, a close personal friend, or any other person identified by you that is involved in your care, or who assists in taking care of you.

    IV. WE ARE PERMITTED TO USE AND DISCLOSE YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES:

  2. 1. Public Health Risks. Our practice may use and disclose your PHI to public health authorities that are authorized by law to collect information for such purposes as maintaining vital records; preventing or controlling disease, injury or disability; notifying a person regarding potential exposure to communicable disease; reporting drug reactions; etc.
    2. Disclosures Required by Law. We may use and disclose your PHI when we are required to do so by federal, state, or local law, including health oversight activities, court or administrative orders or similar legal proceedings.
    3. Deceased Patients. Our practice may release your PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we may also release information in order for funeral directors to perform their jobs.
    4. Organ and Tissue Donation. We may release your PHI to organizations that handle organ, eye or tissue procurement, banking or transplantation.
    5. Research. We may use or disclose your PHI for research purposes with your consent or we will ask our Institutional Review Board to approve a waiver of authorization for disclosure. A waiver of authorization will be based upon assurances from the review board that the researchers will adequately protect your PHI.
    6. Serious Threat to Health or Safety. Our practice may use or disclose you PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual, or the public.
    7. Inmates. Our practice may use or disclose your PHI to correctional institution or law enforcement officials if you are an inmate or under custody of a 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.
    8. Workers’ Compensation. Our practice may use or disclose you PHI for workers’ compensation and similar programs.

    V. YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

  3. 1. For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your PHI, you may contact our Privacy Official with a written request. We will accommodate reasonable request and you will not be penalized for filing a complaint.
    2. Right to Request Restrictions. You may request restrictions on our use and disclosure of your PHI (1) for treatment, payment and health care operations, (2) to individuals (such as a family members or friends) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for restrictions carefully, we are not required to agree to a requested restriction. If you wish to request restrictions, please obtain a request form from our Privacy Official and submit the completed form. If we agree to the requested restrictions, we will comply with your request unless required by law or in emergencies.
    3. Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations. If you wish to make a request, please contact our Privacy Official.
    4. Right to Inspect and Copy Your Health Information. You have the right to inspect and obtain a copy of your PHI including medical and billing records, but not including psychotherapy notes. Please obtain a record request form from the Privacy Official and submit the completed form to the Privacy Official. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Under limited circumstances, we may deny you access to a portion of your records; however, you may request a review of our denial. Another healthcare professional chosen by us will conduct the reviews.
    5. Right to Amend Your Records. You have the right to request that we amend your PHI if you believe it is incorrect or incomplete. If you desire to amend your records, please obtain an amendment request form from the Privacy Official and submit the completed form to the Privacy Official. You must provide us with a reason that supports your request for amendment. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.
    6. Right to Receive an Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. The accounting will not include uses or disclosures for treatment, payment, or healthcare operations, or uses or disclosures pursuant to an authorization you have already provided. If you request an accounting more than once during a twelve (12) month period, our practice will charge you for additional lists.
    7. Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice at any time. To obtain a paper copy of this Notice, please contact our Privacy Official.

    The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices at any time. If we change this Notice, we may make the new notice terms effective for all PHI that we create or maintain. Our practice will post a copy of our current Notice in our office in a visible location and on our Internet site at www.nvafamilypractice.com at all times. You may obtain our most current notice at any time by contacting the Privacy Official.

    You may contact the Privacy Official Carol Newman at:
    4401 Ford Avenue, Suite 250 Alexandria, VA 22302
    (703) 379-8879


    Payment Policies

    Payment is required at time of service. If we are participating providers with your insurance company, your insurance claim will be filed for you. Payment is required at the time of service for co-payments, deductibles, and for non-covered services. You are required to present your insurance card and a picture ID at every visit.

    If we do not participate with your insurance, your receipt will contain all the information needed from the Provider for you to submit your insurance claim. If hospitalization is required, we will submit insurance claims for your hospital care.

  4. A $25 administration fee is charged if payment is not made at the time of service.

  5. A $50 administration fee is charges for un-kept appointments if not cancelled 24 hours in advance.

  6. A $35 administration fee is charged for returned checks.

  7. A $25 administration fee is charged for Prescription Refills not done at the time of the office visit.

  8. We reserve the right to charge a late fee for accounts 30 days past due.

  9. If your past due account(s) is referred to our collection agency and /or attorney, you are responsible for the usual and customary collection agency's fee and/or attorney's fee.



    10. Insurance Policy

    I hereby authorize Northern Virginia Family Practice Associates (NVFPA) to apply for benefits on my behalf for covered services rendered. I request that payment from my insurance carrier (named below) by made directly to NVFPA.

    I understand that I am financially responsible for all charges whether or not paid for insurance. I hereby authorize the doctor to release all information necessary to secure payment benefits.


    Medicare Policy

    I request that payment of authorized Medicare benefits be made either to me or on my behalf to Northern Virginia Family Practice Associates for any services furnished to me by physician or supplier. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services.

    By entering your name below you acknowledge you have read the above Medicare Authorization form. If you do not have Medicare, please type "N/A" in the field below and indicate the date.