NOVA ABC

Northern Virginia Area Bariatric Consultants, PLC

2010 A Opitz Boulevard
Woodbridge, Virginia 22191
Phone 703-494-1020

This notice describes the way in which medical and personal information pertaining to you may be used and disclosed. It also, explains how you can access your health information. Please review it carefully sign the attached acknowledgement receipt at the bottom of this notice and return it to the receptionist.

At NOVA ABC the staff is committed to the protection of your private health information. Within our office the access to your information is limited to those employees who need it in order to perform their jobs.

NOVA ABC may use and disclose protected health information in order to facilitate treatment, collect payments from your health insurance company and also for internal healthcare operations. Examples of these include, but are not limited to, referral to other healthcare providers, life insurance physicals, and home healthcare agencies. Payment examples include your health insurance provider for claims and coordination of benefits, workman's compensation or similar programs: collections agencies, etc. Healthcare operations include auditing of records and internal quality control.

NOVA ABC is required by law to use and/or disclose protected health information without the patients' written consent or authorization in certain circumstances. These include reporting a crime, responding to a subpoenas' warrant or court order; public health officials concerned with controlling disease, disability and injury.

NOVA ABC may use or disclose protected health information to your personal representative whom you have authorized to act on your behalf in making decisions related to your healthcare.

NOVA ABC will contact patients at phone numbers provided to us by the patient in order to give appointment reminders or other information regarding treatment and/or tests results.

NOVA ABC will not use or disclose a patients protected health information as is described in this notice without the individual's written authorization. This authorization may be revoked at anytime in writing. Exceptions are those described above as required by law.

NOVA ABC will abide by this notice which is currently in effect as of April 14, 2003, at the time of disclosure. We reserve the right to revise the terms of this notice and make new provisions effective for all protected health information we maintain.

NOVA ABC will keep a posted copy of our currant privacy practices in our lobby area. Copies of this notice may also be obtained at any time in our office.

Any person/patient, who believes their privacy rights have been violated, may register a complaint with our office manager at 703-494-1020; and to the Secretary of Health and Human Services.

It is our office policy that no retaliatory action will be made against any individual who submits a complaint of non-compliance of the privacy standards.

You have the legal right to inspect or request copies of your protected health information. This requires a written, signed and dated request. (as allowed by State law, reasonable copy fees may apply)

If you believe you health information is inaccurate or incomplete, you may request to amend your information. In the event that we deny your request, we will inform you of our reasons for such a denial in writing.

You have the legal right to request restrictions on certain uses of your protected health information as provided by 45 CFR 164.522(a). By law we are not required to comply with a requested restriction.

Acknowledgement of Privacy Practices

I have received a notice of privacy practices, outlining my rights regarding my protected health information and the specific ways in which my private health information may be used and disclosed as allowed under state and federal law.

__________________________________________ _________________________



Patient or legal representative Date



Relationship of above if not signed by patient__________________________________



In the event patient refused to sign____________________________________________

Document by ________________________________________________________________