This notice describes how medical information about you may be used and disclosed.
IT IS YOUR RESPONSIBILITY TO REVIEW IT CAREFULLY.
LEGAL DUTY
Federal regulations developed under the Health Insurance Portability and Accountability Act require that the Victoria Urological Associates, P.A. (VUA) provide you with this "Notice of Privacy Practices" and how your Personal Health Information is handled.
UNDERSTANDING HEALTH INFORMATION
Each time you visit VUA, a record of the visit is made. Typically this record contains your history, symptoms, examination and test results, diagnoses, treatment and a plan for your future care or treatment. This information, often referred to as your health or medical record, serves as a:
Means of communication among health professionals who care for you and/or your child
It is a legal document that describes the care you received
Means by which you are identified for a third party payor so they may verify the services billed and provided
Tool in the training of health care professionals
Source of data for medical research
Source of data for public health officials
Understanding what is in your record and how your health information is used helps you to ensure it is correct, better understand how your health information is shared with others and allows you to make informed decisions when authorizing disclosure to others.
We will not use or disclose your health information without your authorization except as described in this notice.
HOW WE WILL USE OR DISCLOSE HEALTH INFORMATION
Treatment: We will use for health information for treatment. For example, one of our physicians recognizes that your condition requires hospitalization. In that example the physician would provide the necessary information to the hospital admission office.
Payment: We will use your health information for payment. For example, your insurance company requires precertification of a certain procedure you need to receive.
Health Care Operations: We will use your health information for regular health operations. For example, when our medical records are audited for accuracy and quality analysis.
Business Associates: There are some services provided in VUA through contacts with business associates. Examples include an accountant, attorney, consultants, and software vendor. We only disclose information that is necessary to perform the job we have requested and we require they protect the privacy of this information.
Communication with Family: Health professionals, using their best judgment, may disclose to a family member, other relative or close personal friend or any other person you identify, health information relevant to that person's involvement in your care or the care of your child or payment of services provided.
Research: If you are part of a clinical research trial we may disclose information to researchers when the research has been approved by an Institutional Review Board (IRB) or appropriate entity has approved the research and established methods to ensure privacy of the information.
Funeral Director/Coroner: We may disclose health information to funeral directors and coroners to carry out the duties consistent with the law.
Organ Procurement Organizations: Consistent with the law, we may disclose health information to organ procurement organizations for their designated services.
Marketing & Communication: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs or replacement.
Workers' Compensation: We may disclose health information to the extent authorized by state law governing workers' compensation health care services.
Public Health: As required by law, we may disclose health information to public health officials charged with preventing or controlling disease, injury or disability. For example, we are required to report certain communicable diseases we may be treating you for.
Law Enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. We may disclose information to correctional facilities as required by law.
Reports: We may disclose health information when directed by the appropriate federal oversight agency related to any complaints, surveys or requests.
YOUR HEALTH INFORMATION RIGHTS
Although your health record is the physical property of VUA, the information in the health record belongs to you or your child. You have the following rights:
You can request that we not use or disclose your information related to treatment, payment or health care operations. We ask that such requests be done in writing on a form we will provide. We will review each request individually. Although we will consider your request we are not obligated to honor it. We will inform you of our decision as quickly as possible.
You may request to be contacted by alternate means or at alternate locations. Such requests must be made in writing on a form we will provide. We will review each request individually and will attempt to honor all reasonable requests.
You may request to inspect a copy of your or your child's medical record. Such requests must be made in writing on a form we will provide. We will attempt to provide you with this information within thirty (30) days. We may charge a reasonable fee for copies.
If you believe that any information in the record is incorrect or if you believe important information is missing you may request that we correct or amend the information. Such requests must be made in writing on a form we will provide.
You may request a written accounting of disclosures we have made of your health information after April 14, 2003. This is limited to disclosures OTHER than treatment, payment or health care operations. We will maintain these records for six (6) years. We will respond to a request within sixty (60) days if possible. Such requests must be made in writing on a form we will provide. If you request an accounting more than once within a twelve (12) month period you will be charged a reasonable fee.
You have a right to a paper copy of this notice.
We must obtain a written authorization from you to disclose information other than treatment, payment, or health care operations. You have the right to revoke this authorization to the extent we have already used or disclosed the information.
CONCERNS AND COMPLAINTS
If you are concerned that VUA may have violated your privacy rights or if you disagree with any decision we have made regarding the use or disclosure of your information please contact our Privacy Officer at the address listed below. You may also send a written complaint to the US Department of Health and Human Services.
For further information or complaints, contact the following person:
Dan Keller, CMPE
Privacy Officer
Victoria Urological Associates, P.A.
100 Victoria Road
Asheville, NC 28801
CHANGES TO THIS POLICY
VUA may change or update this policy at any time. When new changes are made a new "Notice of Privacy Practices" will be posted in the waiting room and on our website (www.VictoriaUrological.com) and will be provided at check-in at your next visit. You may request an updated copy of our notice at any time.
The following is an Acknowledgement of Receipt Form. It is to be signed by the appropriate person and returned to Victoria Urological Associates, P.A. to maintain on record.
Victoria Urological Associates, P.A. (VUA) has provided me their "Notice of Privacy Practices" for my review.
I understand that the purpose of this notice is to inform me of my rights in regard to my protected health information, or in the case of a minor, my child's protected health information and also the ways in which VUA may use that protected health information.
___________________________
Patient/Parent/Guardian Signature
________/________/________
Date
Victoria Urological Associates
100 Victoria Road
Asheville, NC 28801
Tel: 828.254.8883
Fax: 828.253.2024
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