Notice of Privacy Practices

If you have any trouble submitting this form, please download and print the pdf and fax it to us at (703) 530-9805. Download

This notice describes how health information about you may be used and disclosed and how you can get access to this Information.

Please review carefully. The privacy of your health information is important to us.

Our Legal Duty: We are required by applicable federal and state law to maintain the privacy of your health information. We are also required by law to give you this notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect on April 14th, 2003, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and applicable law permits the terms of this notice at any time, provided such changes. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available.

You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.

 

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations as described below:

Treatment: We may use or disclose your health information to a physician or other health care provider providing treatment to you.

Payment: We may use or disclose your health information to obtain payment for services we provide to you. All services rendered by Calvary Counseling Center are final and non-refundable.

Healthcare Operations: We may use or disclose information about your health in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use and disclosure of your health information for treatment, payment, or healthcare operations, you may give us written authorization to use your health information or disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patients Rights section of this notice. We may disclose information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification (including identifying or location) of a family member, your personal representative or other person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experiences with common practice to make reasonable inferences of your best interest in allowing a person to pick up forms of health information.
Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law as described in your signed confidentiality statement.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert serious threat to your health or to the health and safety of others.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards or letters).

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format that you request unless we cannot practically do so. You must make a request in writing to obtain access to your health information. You may submit your written request to the contact information listed at the end of this notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. We will charge:

  • Copy pages 1 through 25 $1.00 each
  • Copy pages 26 through 50 $0.70 each
  • Copy pages in excess of 50 $0.40 each

and $85.00 per hour of staff time to generate your health information no matter what format. Please give the office 72 hours advance notice for any written letter/form requests and or copies.

 If you prefer, we will prepare a summary or an explanation of your healthcare information for a similar fee.

Disclosure Accounting: You have a right to receive a list of instances in which we or our business associates disclosed your healthcare information for purposes other than treatment, payment, healthcare operations and certain other activities, for the last six years, but not before April 14, 2003. We will charge:

  • Copy pages 1 through 25 $1.00 each
  • Copy pages 26 through 50 $0.70 each
  • Copy pages in excess of 50 $0.40 each

and $85.00 per hour of staff time to generate the list you requested.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or alternative locations. You must make such a request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. We will communicate with you about your health information by alternative means or to alternative locations if we are able to do so.

Amendment: You have the right to request that we amend your health information. Your request must be in writing and it must explain why the information should be amended. We may deny your request under certain circumstances.

QUESTIONS AND COMPLAINTS

If you want more information about privacy practices or have questions/concerns, please contact as specified below. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use and disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed below. You also may submit a written complaint to the U.S. Department of Health and Human Services. We support your right to privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Calvary Counseling Center
Address: 9300 Forest Point Circle, Manassas, VA 20110
Telephone: (703) 530-9800 Fax: (703) 530-9805
www.calvarycounselingcenter.com

ACKNOWLEDGEMENT FORM

I hereby testify that I have received the Notice of Privacy Practices and I have been provided an opportunity to review it thoroughly. I hereby certify that I have read and understood the Notice of Privacy Practices and that I have received answers to questions regarding my privacy rights.