Fairfax Radiological Consultants, P.C
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 Read It Carefully.

Fairfax Radiological Consultants, P.C. ("FRC") is committed to maintaining the privacy of your health information. We are required by law to:

• Maintain the privacy of medical information provided to us;
• Provide notice of our legal duties and privacy practices;
• Promptly notify individuals if a breach occurs that may compromise the privacy or security of their protected information;
• Abide by the terms of our Notice of Privacy Practices currently in effect.

WHO WILL FOLLOW THIS NOTICE:
This notice describes the health information privacy practices of Fairfax Radiological Consultants, P.C. The words "we" or "our" used in this Notice refer to the company (FRC), its employees and radiologists providing services at this facility.

HOW WE MAY USE AND DISCLOSE INFORMATION:
We may use and disclose personal and identifiable health information about you in different ways. Except for the purposes described below, we will use and disclose your health information only with your written permission. You may revoke such permission at any time by providing a written notice to the facility or to our company Privacy Officer.

For Treatment: We are permitted to use and disclose your health information to provide you with medical related health care services. For example, we are permitted to disclose medical information about you to doctors, nurses, technicians/technologists, or other personnel, including persons outside our offices, who are involved in your medical care and need the information to provide the medical care.

For Payment: We are permitted to use and disclose information about you to bill and receive payment for the services you received at our facilities. For example, we may need to give your insurance company specific information about your current medical condition in order to receive payment for the services that we have furnished you. We may also inform your insurance company of any services and/or tests that you are going to receive and your diagnosis to obtain prior approval/preauthorization or to determine whether the service is covered.

For Health Care Operations: We are permitted use and disclose information about you for operation of our business. These uses and disclosures are necessary to make sure that all of our patients receive quality care. For example, we may use your health information for training/education and for quality assurance to assist us in making improvements in the care and services we provide. We are permitted to disclose you health information to accrediting organizations.

For Appointment Reminders/ New Services: Unless you request otherwise, we are permitted to use and disclose your health information to provide you with appointment reminders or other information about services we offer that might be of interest to you. For example, we are permitted to contact our female patients to announce new services we are offering to support Breast Cancer Awareness.

For Research: We may use or disclose certain health information about your condition and treatment for research purposes where an Institutional Review Board or a similar body referred to as a Privacy Board determines that your privacy interests will be adequately protected in the study. We may also use and disclose your protected health information to prepare or analyze a research protocol and for other research purposes.

As Required or Permitted by Law: To comply with federal, state and local laws , we may be required to report specific health information to legal authorities such as law enforcement officials, court officials and/or government agencies. For example, we are required to provide information in cases of abuse, neglect, domestic violence or to in response to a subpoena or court order. We may disclose information about you for legal or administrative proceedings that involve you. We may release such information upon order of a court or administrative tribunal. We may also release health information in the absence of such an order and in response to a discovery or other lawful request, if efforts have been made to notify you or secure a protective order.

For Public Health Risks: We may disclose specific health information about you in connection with certain public health reporting activities. For instance, we may disclose such information to a public health authority authorized to collect or receive PHI for the purpose of preventing or controlling disease, injury or disability, or at the direction of a public health authority, to an official of a foreign government agency that is acting in collaboration with a public health authority. Public health authorities include state health departments, the Centers for Disease Control, the Food and Drug Administration, the Occupational Safety and Health Administration and the Environmental Protection Agency, to name a few.

For Health Oversight Activities: We may disclose health information in connection with certain health oversight activities of licensing and other agencies. Health oversight activities include audit, investigation, inspection, licensure or disciplinary actions, and civil, criminal, or administrative proceedings or actions or any other activity necessary for the oversight of 1) the health care system, 2) governmental benefit programs for which health information is relevant to determining beneficiary eligibility, 3) entities subject to governmental regulatory programs for which health information is necessary for determining compliance with program standards, or 4) entities subject to civil rights laws for which health information is necessary for determining compliance.

To Coroners, Medical Examiners or Funeral Directors: We may release health information to a coroner or medical examiner to identify a deceased person or determine the cause of death.

For Organ and Tissue Donation: We may release health information about you to organ procurement organizations.

For Workers' Compensation: We may release specific health information about you to workers' compensation or similar programs.

To Avert a Serious Threat to Health or Safety: Information about you also will be disclosed when necessary to prevent a serious threat to your health and safety or the health and safety of others

For Military Personnel and Veterans: If you are a member of the Armed Forces, we may release health information about you as required by military command authorities. We also may release personal health information about foreign military personnel to the appropriate foreign military authority.

For Inmates or Individuals in Custody: If you are an inmate, we may release health information about you to a correctional institution where you are incarcerated or to law enforcement officials.

For National Security: We may disclose health information for national security and intelligence activities and for the provision of protective services to the President of the United States and other officials or foreign heads of state.

To Our Business Associates: We sometimes work with outside individuals and businesses that help us operate our business successfully. We may disclose your health information to these business associates so that they can perform the tasks that we hire them to do. Our business associates must guarantee to us that they will respect the confidentiality of your personal and identifiable health information.

To Individuals Involved in Your Care or Payment for Your Care: Unless you object in writing and there is not an emergency situation, we may disclose information to individuals identified by you involved in your care or in the payment for your care. This includes people and organizations that are part of your "circle of care" -- such as your spouse, persons accompanying you to your appointment, your other doctors, or an aide who may be providing services to you.

Other Uses and Disclosures of Your Health Information: Other uses and disclosures of your health information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us with such permission, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose personal information about you for the reasons covered by your written authorization. We will be unable to take back any disclosures already made based upon your original permission. The following uses and disclosures of your health information will be made only with your written authorization:

1. Uses and disclosures of specific health information for marketing and fund raising purposes;
2. Disclosures that constitute a sale of your health information.

YOUR RIGHTS:
When it comes to your health information, you have certain rights. You have the right to:

1. Inspect and copy your health information: With a few exceptions, you have the right to inspect and copy of your medical and billing records. We are permitted to charge you a reasonable fee for copying, postage and handling. If your health information is maintained in an electronic format, you have the right to request than an electronic copy of your record be given to your or transmitted to another individual or entity. We will make every effort to provide access to your records in the form or format you request, if it is readily producible in such form or format otherwise your record will be provided in either our standard format or readable hard copy form.
2. Request a correction to your health information: If you believe that information in your records is incorrect or incomplete, you have the right to ask us to correct the existing information or correct the missing information. You will be asked to make such requests in writing . We are not required to honor your request if we did not create the information you are requesting be amended or if it is our professional opinion that the information in your record is accurate or complete. We will respond to your request in writing within the timeframe allowed by law.
3. Request confidential communication: You have the right to request that you receive communications containing your protected health information from us by alternative means or at alternative locations. For example, you may ask that we only contact you at home or by mail or send mail to a different address.
4. Request restrictions to what we use or share: You have the right to ask for restrictions on the ways in which we use and disclose your medical information beyond those imposed by law. We will consider your request, but we are not required, to accept it.
5. Self-Pay and/or Out-of-Pocket Payments: If you paid for a specific item or service out of pocket in full (i.e. -you have requested that we NOT bill your health insurance and you have paid for the services provided), you have the right to ask that your health information with respect to that item or service not be disclosed to your health plan for purposes of payment or health care operations, and we will honor that request.
6. Breach Notification: You have the right to be notified upon a breach of any of your protected health information.
7. Request a list of disclosures: You have a right to ask for a list of instances when we have used or disclosed your health information for reasons other than your treatment, payment for services furnished to you, our health care operations, or disclosures you give us authorization to make. If you ask for this information from us more than once every twelve months, we may charge you a fee.
8. Obtain a copy of this privacy notice: You have the right to a copy of this Notice in paper form. You may also obtain a copy of this notice from our web site, www.fairfaxradiology.com.

CHANGES TO THIS NOTICE
We reserve the right to make changes to this notice at any time. We reserve the right to make the revised notice effective for personal health information we have about you as well as any information we receive in the future. In the event there is a material change to this Notice, the revised Notice will be posted. In addition, you may request a copy of the revised Notice at any time.

COMPLAINTS/COMMENTS
If you have a complaint concerning our Privacy Policy, or wish to obtain more information concerning this Notice of Privacy Practices or to exercise any of your rights, please contact us in writing at Fairfax Radiological Consultants, P.C Attention: Privacy Officer, 2722 Merrilee Drive, Suite 230 Fairfax, VA 22031-4400. We will not retaliate against anyone for filing a complaint.

If you have any further unresolved complaints concerning our Privacy Policy, you may contact: US Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, Washington, D.C. 20201, calling 1-877-696-6775 or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

This Notice of Privacy Policy revised and effective September 23, 2013. Original effective date April 14, 2003.

Spanish Translation of the Privacy Policy:

Spanish Privacy Policy