NIRSCHL ORTHOPAEDIC CENTER
FOR SPORTS MEDICINE AND JOINT RECONSTRUCTION
1715 N George Mason Drive, Suite 504, Arlington, Va. 22205 Fax: (703) 522-2603
Robert P. Nirschl, M.D., M.S. William C.Lennen, M.D.
(703 525-2200 (703) 525-5518
Eric J. Guidi, M.D. Patrick St. Pierre, M.D.
(703) 841-0551 (703) 894-1123
Derek Ochiai, M.D.
(703) 525-8183
PF-1000 Notice of 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
Treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.
Payment. Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.
Health care operations. Your health information may be used as necessary to support the day-to-day activities and management of Nirschl Orthopaedic Center For Sports Medicine and Joint Reconstruction. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.
Law enforcement. Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.
Public health reporting. Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state's public health department.
Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.
Appointment reminders. Your health information provided may be used by our staff to call or send you appointment reminders. If you have an answering machine or voice mail on your home telephone and do not want us to leave a message notifying you of your next appointment, please contact our Privacy officer in writing.
Information about treatments. Your health information may be used to send you information on the treatment and management of your medical condition that you may find to be of interest. We may also send you information describing other health-related goods and service that we believe may interest you.
Individual Rights You have certain rights under the federal privacy standards.
These include:
q The right to request restrictions on the use and disclosure of your protected health information
q The right to receive confidential communications concerning your medical condition and treatment
q The right to inspect and copy your protected health information
q The right to amend or submit corrections to your protected health information
q The right to receive an accounting of how and to whom your protected health information has been disclosed
q The right to receive a printed copy of this notice
Nirschl Orthopaedic Center For Sports Medicine and Joint Reconstruction Duties
We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice. We have the right to revise our Privacy Practices. As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain.
Requests to Inspect Protected Health Information
As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting the Receptionist/Secretary. Please be aware Virginia law allows a $10 clerical fee plus .50 a page for the first fifty pages and .25 a page there after for copies of medical records provided.
Concerns or Complaints
If you would like to submit a comment, concern, or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:
Privacy Officer
Nirschl Orthopaedic Center For Sports Medicine and Joint Reconstruction
1715 North George Mason Drive #504
Arlington, VA 22205
If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint.
Contact Person
The name and address of the person you can contact for further information concerning our privacy practices is:
Privacy Officer
Nirschl Orthopaedic Center For Sports Medicine and Joint Reconstruction
1715 North George Mason Drive #504
Arlington, VA 22205
703-525-8183
Effective Date
This Notice is effective on or after April 14, 2003
