Privacy Policy

 
 

Protecting your privacy is important to Stafford Urgent Care/ Stafford Primary Care (SUPC) and its employees. We will continually strive to maintain that trust. This notice describes how medical information about you may be collected, used and disclosed and how you can get access to this information. Please read it carefully. The following policy serves as a standard for all SUPC employees for collection, use, retention, and security of protected health information, which is individually identifiable health information that includes both health care information and demographic details such as address, gender or date of birth. This notice is effective as of April 14, 2003.

 

Information We Collect

 

We may collect “protected health information” about you from the following sources:

 

•     Information we receive from you when applying for treatment, setting up appointments and receiving medical attention; and

•     Information we receive from third parties, such as referring medical offices or consumer reporting agencies.

 

“Protected health information” is information about you that we obtain in order to provide medical treatment and services and to receive payment. Examples are medical records, addresses, gender, Social Security numbers, birth dates, etc. Our records will also contain information about your insurance coverage and claims history.

 

Information We Disclose

 

We are permitted under law to disclose protected health information about you to “non-affiliated third parties” (i.e., third parties that are not members of our corporate family) in certain circumstances. For example, we may disclose protected health information about you to third parties to:

•     assist us in servicing your account with us (e.g., insurance carriers or to obtain your address from other sources when not available or incorrect);

•     collection agencies when payment for services is not timely rendered;

•     government regulators; in response to subpoenas or for law enforcement purposes;

•     employers to evaluate eligibility for worker’s compensation benefits; and to

•     other medical practices for the purpose of providing continued or additional treatment.

We do not disclose any protected health information about you to any other third parties, except as authorized by you. However, using our best judgment, we may disclose to a family member, other relative, close personal friend or any other person you identify health information relevant to that person’s involvement in your care or payment related to your care. If you leave our practice or become an inactive patient, we will continue to adhere to the privacy policies and practices as described in this notice. SUPC does not have joint marketing agreements with other entities and we will not share your protected health information with them to offer products and services.

 

 

Your Rights

Although your health record is the physical property of SUPC, the information belongs to you. You have the right to:

•     Obtain a paper copy of this notice on request.

•     Inspect and receive a copy of your health record (up to the most recent 6-year period) as provided for in 45 CFR 164.524.

•     Amend your health record as provided in 45 CFR 164.528.

•     Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528.

•     Request communications of your health information by alternative means or at alternative locations.

•     Revoke your authorization to use or disclose health information except to the extent that action has already been taken. We are not required to agree to such a request for restriction if we believe it will interfere with treatment, payment or health operation activities.

 

If You Have A Complaint About Matters Concerning Protected Health Information

SUPC takes seriously its responsibility to prevent improper disclosure of Protected Health Information. If you feel we have not protected your information adequately, you should contact our Privacy Officer, Lew Sherman, to discuss your concerns. Contact can be made in person at our Garrisonville Road address, telephonically at 540-657-9633, by fax at 540-657–5925 or by mail at P.O. Box 729, Garrisonville, VA 22463. We will attempt to address your concerns and will modify our policies and practices, if necessary. Any person or patient may file a complaint to the Secretary of Health and Human Services if they believe their privacy rights have been violated. The address is listed below:

 

Office for Civil Rights

U.S. Department of Health and Human Services

200 Independence Avenue, S.W.

Room 509F, HHH Building

Washington, D.C. 20201

 

There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights.

 

Changes to Our Privacy Policy

 

We will provide you with a copy of our privacy policy upon request. In addition, our policy will be prominently posted in our waiting room for all to see. We will occasionally review our policy and we reserve the right to amend it, as necessary. The most current policy will always be posted for our patients to see.

 

Patient’s Name_______________________

Signature of Patient or Legal Guardian_______________________________

Date:____________________

Dear Patient,