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This notice is to inform you of the process by which medical information about you may be used and disclosed, and how you as our patient can get access to this information.

Uses and Disclosures of Your Health Information

Treatment: Your health information may be used by staff members of Elissa Driban & Associates or disclosed to other health care professionals for the purpose of evaluating and treating your health problems and ascertaining your medical conditions. For example, progress notes and reports as well as initial evaluations and reevaluations will be available in your medical record to all health professionals who may provide care or who may be consulted by members of our staff.

Payment: Your health information may be used to seek payment from your health plan or other types of insurers from whom you subscribe for insurance coverage, or from credit card companies you may use to pay for services. For example, your health insurer may require that we send them information on dates of service, treatment received, and the medical problem necessitating the treatment.

Health Care Operations: Your health information may be used statistically to provide operational and budgetary information to support the services provided by Elissa Driban & Associates. For example, auditing of charts may be done to evaluate the quality of care provided at this facility.

Law Enforcement: It may be necessary to disclose your health information to law enforcement agencies, without your authorization, to comply with government audits and or inspections, to comply with on-going law enforcement investigations, or mandated reporting to government agencies. In addition, your records may be subject to legal subpoena by law enforcement agencies.

Public Health Reporting: Should it be required by law, your health information may be disclosed to public health agencies. An example might be that we are required by law to report certain communicable diseases to the state's public health department.

Other Uses and Disclosures Require your Authorization: Disclosure of your health information, or use of it for any purpose other than those described above requires your specific written authorization. You have the right to change your mind about such disclosure, and may express a revocation of same in writing to Elissa Driban & Associates. It must be noted that if you do revoke authorization to disclose medical information, it will not affect or undo any use of or disclosure of information that occurred before you notified Elissa Driban & Associates of your decision to revoke.

Additional Uses of Information

Appointment Reminders: Your health information will be used by our staff to provide you with appointment reminders.

Information About Treatments: Your health information may be used to send you information on the treatment or management of your medical problem, or of products and/or services, literature, or new technology that you may find of interest.

You have certain rights under the Federal privacy standards. These rights include:

We are required by law to maintain the privacy of your protected health information, and to provide you with a copy of this notice of privacy practices. In addition, we are required to abide by the privacy policies and practices described in this notice.

As permitted by law, we reserve the right to amend or modify our privacy practices and policies from time to time. Such changes may be required by changes in Federal or State statute or regulation. Such revisions will be applied to all protected health information that we maintain, and will be available at our facility upon your request.

As permitted by Federal regulations, we require that requests to inspect or copy protected health information be submitted in writing. You may request a form from us to access your protected health information by contacting Elissa Driban, PT, the privacy officer.

If you wish to submit a complaint or comment regarding our privacy practices, or if you believe your privacy rights have been violated, you may send a letter outlining your concerns to:

Elissa Driban, PT, OCS
5530 Wisconsin Avenue, Suite 1650
Chevy Chase, MD 20815

You may also file a written complaint with the Office of Civil Rights. Effective date of this notice is August 9, 2004.

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