NOTICE OF PRIVACY PRACTICES

EFFECTIVE APRIL 14, 2003

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU (AS A PATIENT OF THIS PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

If you have any questions about this notice, please contact in writing: Jack H. Morana, Administrator/CEO, Town Center Orthopaedic Associates, P.C., 1860 Town Center Drive, Suite 300, Reston, Virginia 20190 or by calling (703) 435-6604.

OUR COMMITMENT TO YOUR PRIVACY

This notice applies to the information and records we have about your health, health status, and the health care and service(s) you receive at this office. It is being provided to you as a requirement of the Health Insurance Portability and Accountability Act of 1966 (“HIPAA”). This Notice describes how, when and why we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. “Protected health information” means any written, recorded or oral information about you, including demographic data, that may identify you or that can be used to identify you, that is created or received by the Practice, and that relates to your past, present or future physical or mental health or condition, the provision of health care to you, or the past, present or future payment for the provision of health care to you.

WE ARE REQUIRED BY LAW TO:

• Make sure that your protected health information is kept confidential
• Give you this notice of our legal duties and privacy practices with respect to protected health information about you
• Abide by the terms of this notice as currently in effect.

The following describes the different areas in which we are permitted by HIPAA to use and disclose your protected health information. Disclosure of your protected health information for the purposes described in this Notice may be made in writing, orally, or electronically (e-mail), by facsimile or by other means.

• Treatment Our practice may use protected health information about you to provide you with medical treatment or services. For example, we may ask you to have laboratory test (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your health information to write a prescription for you, or we might disclosure your health information to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, our physicians and clinical staff – may use or disclose your health information in order to treat you or to assist others in your treatment. Additionally, we may disclose your health information to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your health information to other health care providers for purposes related to your treatment.


• Payment Our practice may use and disclose your protected health information so that the treatment and services you receive at this office may be billed to and payment collected from you, an insurance company or a third party. For example, we may contact your health insurer to certify that you are eligible for benefits and for what range of benefits, and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your health information to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your health information to bill you directly for services and items. Finally, we may also disclose your health information to other health care providers and entities to assist in their billing and collection efforts.


• Health Care Operations Our practice may use and disclosure your protected health information to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your health information to evaluate the quality of care your received from our staff, or to conduct cost-management and business planning activities for our practice to help us decide what additional services we should offer, how we can become more efficient, or whether certain new treatments are effective. We may also disclose your health information to other health care providers and entities to assist in their health care operations.


• Business Associates There are some services provided in our organization through contracts with business associates. An example would be the clearinghouse we use to process our claims and electronically transmit them to your insurance company. To protect your health information, however, we require the business associate to sign a contract with us that they and their employees will appropriately safeguard your health information.


• Appointment Reminders Our practice may use and disclose your protected health information to contact you and remind you of an appointment. We may leave a message on your answering machine or with the person answering the telephone at your residence, or send you a written reminder by a postcard or letter.


• Sign-in Sheets We may use sign-in sheets in certain locations to check you into the facility. We may also call your name in the waiting room area.


• Treatment Options We may use and disclose your protected health information to inform you of potential treatment options or alternatives that may be of interest to you.


• Health-Related Benefits and Services Our practice may use and disclose your protected health information to inform you of health-related benefits or services may be of interest to you.


• Release of Information to Family/Friends Our practice may release your protected health information to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child to the orthopaedist’s office for treatment of a sore knee. In this example, the babysitter may have access to this child’s medical information.


• Disclosures Required By Law Our practice will use and disclose your protected health information when we are required to do so by federal, state or local law.

• Public Health Risks Our practice may disclose your protected health information to public health authorities that are authorized by law to collect information for the purpose of:


• Maintaining vital records, such as births and deaths
• Reporting child abuse or neglect
• Preventing or controlling disease, injury or disability
• Notifying a person regarding potential exposure to a communicable disease
• Notifying a person regarding a potential risk for spreading or contracting a disease or condition
• Reporting reactions to drugs or problems with products or devices
• Notifying individuals if a product or device they may be using has been recalled
• Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.
  


• Health Oversight Activities Our practice may disclose your protected health information to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.


• Lawsuits and Administrative Disputes Our practice may use and disclose your protected health information in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your health information in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.


• Law Enforcement We may release protected health information if asked to do so by a law enforcement official:


• Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement
• Concerning a death we believe has resulted from criminal conduct
• Regarding criminal conduct at our offices
• In response to a warrant, summons, court order, subpoena or similar legal process
• To identify/locate a suspect, material witness, fugitive or missing person
• In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)


• Deceased Patients Our practice may release protected health information to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.



• Eye, Organ and Tissue Donation Our practice may release your protected health information to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.



• Research Our practice may use and disclose your protected health information for research purposes in certain limited circumstances. We will obtain your written authorization to use your health information for research purposes except when an Internal Review Board or Privacy Board has determined that the waiver of your authorization satisfies the following: (i) the use or disclosure involves no more than a minimal risk to your privacy based on the following: (A) an adequate plan to protect the identifiers from improper use and disclosure; (B) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (C) adequate written assurances that the health information will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted; (ii) the research could not practicably be conducted without the waiver; and (iii) the research could not practicably be conducted without access to and use of the protected health information.



• Serious Threats to Health or Safety Our practice may use and disclose your protected health information 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. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.



• Military Our practice may disclose your protected health information if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.



• National Security Our practice may disclose your protected health information to federal officials for intelligence and national security activities authorized by law. We also may disclose your health information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.



• Workers’ Compensation Our practice may release your protected health information for workers’ compensation and similar programs.

We will not use or disclose your protected health information for any purpose other than those identified in the previous sections without your specific, written Authorization. If you give us Authorization to use or disclose health information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.

If we have HIV or substance abuse information about you, we cannot release that information without a special signed, written authorization (in addition to the Authorization mentioned above) from you. In order to disclose these types of records (for purposes of treatment, payment or health care operations), we will have to have both your signed Authorization and a special consent that complies with the law governing HIV or substance abuse records.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

Your health record is the physical property of Town Center Orthopaedic Associates, P.C. We are required to retain our records of the care we provide to you, but the information belongs to you. You have the following rights regarding protected health information we maintain about you:

• Inspection and Copies You have the right to inspect and obtain a copy of the protected health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to our Administrator/CEO at 1860 Town Center Drive, Suite 300, Reston, Virginia 20190 in order to inspect and/or obtain a copy of your protected health information. Our practice will charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct the reviews.
  
  
• Amendment You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to our Administrator/CEO at Town Center Drive, Suite 300, Reston, Virginia 20190. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the protected health information kept by or for the practice; (c) not part of the protected health information which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.
  
  
• Accounting of Disclosures All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your protected health information for non-treatment, non-payment or non-operations purposes. Use of your protected health information as part of the routine patient care in our practice is not required to be documented. For example, the physician sharing information with other clinical staff; or the billing department using your information to file your insurance claim. In order to obtain an “accounting of disclosures,” you must submit your request in writing to our Administrator/CEO at 1860 Town Center Drive, Suite 300, Reston, Virginia 20190. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free or charge, but our practice will charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
  
  
• Confidential Communications You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to our Administrator/CEO at 1860 Town Center Drive, Suite 300, Reston, Virginia 20190 specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.
  
  
• Requesting Restrictions You have the right to request a restriction in our use or disclosure of your protected health information for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your health information, you must make your request in writing to our Administrator/CEO at 1860 Town Center Drive, Suite 300, Reston, Virginia 20190. Your request must describe in clear and concise fashion the information you wish restricted; whether you are requesting to limit our practice’s use, disclosure or both; and, to whom you want the limits to apply.
  
  
• Right to a Paper Copy of This Notice You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact our Administrator/CEO at 1860 Town Center Drive, Suite 300, Reston, Virginia, 20190.

FOR MORE INFORMATION OR TO FILE A COMPLAINT

If you believe your privacy rights have been violated, or you disagree with a decision we made about access to your protected health information or in response to a request you made to amend or restrict the use or disclosure of your medical information, or to have us communicate with you by alternative means or at an alternative location, you may file a complaint by contacting:

Jack H. Morana, FACHE

Administrator/CEO

Town Center Orthopaedic Associates, P.C.

1860 Town Center Road, Suite 300

Reston, Virginia 20190

(703) 435-6604

If you are not satisfied with how our office handled your complaint, you may submit a written complaint to:

Secretary of the Department of Health and Human Services

200 Independent Avenue, S.W.

Washington, D.C. 20201

We support your right to privacy of your protected health information. We will not retaliate or penalize you in any way if you choose to file a complaint with us, or the Department of Health and Human Services.

Effective Date The effective date of this notice is April 14, 2003