Patient Privacy

Monarch Women’s Wellness, P.C. NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW PHI ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

OUR PLEDGE REGARDING PHI

This Notice of Privacy Practices is being provided to you as a requirement of the privacy regulations issued under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  This notice describes how Monarch Women’s Wellness may use and disclose medical information about you to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law.  It also describes your rights to access and control medical information about you.  Your medical information (i.e., “protected health information” or “PHI” for any purposes of HIPAA) is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition.  We are required by law to maintain the privacy of your PHI, and we must abide by the terms of this notice.

As required by law, we will only use or disclose your PHI in ways consistent with what is stated in our Privacy Notice.

The effective date of this Privacy Notice is April 14, 2003.

We reserve the right to change the terms of this Privacy Notice and to make a new Privacy Notice effective for all PHI we maintain.  In the event of a change to our Privacy Notice, we will provide you with the new Privacy Notice upon request.

We have designated a Privacy Officer whom you may consult to ask questions and bring up concerns you might have about your PHI and how it is handled.  You can reach our Privacy Officer by calling 757-673-8383 or writing to 3802 Poplar Hill Dr., Suite C, Chesapeake, VA 23321.

ACKNOWLEDGEMENT OF RECEIPT OF THIS PRIVACY NOTICE

You are receiving our current Privacy Notice and are asked to sign and acknowledgment that you have received it.  You may provide the signed acknowledgement by: signing the last page of this Privacy Notice and returning it to reception desk or a nurse, physician or other staff member, or by mailing it to the following address:

3802 Poplar Hill Drive, Suite C, Chesapeake, VA 23321

Attention: Privacy Officer.

If after, April 14, 2008, your initial contact with our office is through electronic mail, you will be asked to acknowledge receipt of this Privacy Notice by replying to our electronic message that

Individuals Involved in Your Care or Payment for Your Care.  We may release PHI about you to a friend or family member who is involved in your medical care.  We may also give information to someone who helps pay for your care.  We may also tell your family or friends your condition and that you are in a hospital.

Research.  Under certain circumstances, we may use and disclose PHI about you for research purposes.  For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition.  All research projects, however, are subject to a special approval process.  This process evaluates a proposed research project and its use of PHI, trying to balance the research needs with individuals’ need for privacy of their PHI.  Before we use or disclose PHI for research, the project will have been approved through this research approval process, but we may, however, disclose PHI about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the PHI they review does not leave our office.  We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care.

As Required By Law.  We will disclose PHI about you when required to do so by federal, state, or local law.

To Avert a Serious Threat to Health or Safety.  We may use and disclose PHI about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.  Any disclosure, however, would only be to someone able to help prevent the threat.

Organ and Tissue Donation.  If you are an organ donor, we may release PHI to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans.  If you are a member of the armed forces, we may release PHI about you as required by military command authorities.  We may also release PHI about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation.  We may release PHI about you for public health activities.  These activities generally include the following:

  • To prevent or control disease, injury or disability
  • To report births and deaths
  • To report child abuse or neglect
  • To report reactions to medications or problems with products
  • To notify people of recalls of products they may be using
  • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition

Signed authorization you give us that is attached to a request to us for you PHI.  We will also keep a record of when, to whom and what we provided in response to the request for disclosure.  If you have signed authorization for use to use or disclose your PHI, and decide you want to revoke the authorization, you have the right to revoke it.  You must revoke the specific authorization in writing and deliver it to the Privacy Officer at 3802 Poplar Hill Drive, Suite C, Chesapeake, VA 23321 before your revocation is effective.  Once we receive the revocation, or have actual knowledge that you have revoked the authorization, we will make a note of it to assure that we do not make future disclosures pursuant to your original authorization.

YOUR RIGHTS REGARDING PHI ABOUT YOU

You have the following rights regarding PHI we maintain about you:

Right to Inspect and Copy.  You have the right to inspect and copy PHI that may be used to make decisions about your care.  Usually, this includes medical and billing records, but does not include psychotherapy notes.

To inspect and copy PHI that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer at 3802 Poplar Hill Dr., Suite C, Chesapeake, VA 23321.  If you request a copy of the information, we may charge a fee for the costs of copying mailing or other supplies associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances.  If you are denied access to PHI, you may request that the denial be reviewed.  Another licensed health care professional chosen by us will review your request and the denial.  The person conducting the review will not be the person who dined your request.  We will comply with the outcome of the review.

Right to Amend.  If you feel that PHI we have about you is incorrect or incomplete, you may ask us to amend the information.  You have the right to request and amendment for as long as the information is kept by or for the Monarch Women’s Wellness

To request an amendment, your request must be made in writing and submitted to the Privacy Officer at 3802 Poplar Hill Drive, Suite C, Chesapeake, VA 23321.  In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request.  In addition, we may deny your request if you ask us to amend information that:

  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the PHI kept by or for us;
  • Is not part of the information which you would be permitted to inspect and copy, or
  • Is accurate and complete.

Our current Privacy Notice will also be posted in our office for you to review.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us.  To file a complaint with us, contact the Privacy Officer at 757-673-8383.  All complaints must be submitted in writing to the Privacy Officer at 3802 Poplar Hill Dr. Suite C, Chesapeake, VA 23321.

You also have the right to complain to the Office of Civil Rights.

You will not be penalized for filing a complaint.