Notice of Information Practices

This notice describes how information about you may be used and disclosed and how you can gain access to this information. Please review it carefully.

Effective date of this notice is April 14, 2003.

1. Hemorrhoid Solutions may use and disclose protected health information for treatment, payment and healthcare operations. Examples of these include, but are not limited to, requested preschool, sports physicals, referral to nursing homes, foster care homes, home health agencies and/or referral to other providers for treatment. Payment examples include, but are not limited to, insurance companies for claims including coordination of benefits with other insurers; collection agencies. Healthcare operations include, but are not limited to, internal quality control and assurance including auditing of records.

2. Hemorrhoid Solutions is permitted or required to use or disclose protected health information without the individual's written consent or authorization in certain circumstances. Two examples of such are for public health requirements or court orders.

3. Hemorrhoid Solutions will not make any other use or disclosure of a patient's protected health information without the individual's written authorization. Such authorization may be revoked at any time. Revocation must be written.

4. Hemorrhoid Solutions will abide by the terms of this notice currently in effect at the time of the disclosure.

5. Hemorrhoid Solutions reserves the right to change the terms of its notice and to make new notice provisions effective for all protected health information that it maintains. The Hemorrhoid Solutions will provide each patient with a copy of any revisions of its Notice of Information Practices at the time of their next visit, or at their last know address if there is a need to use or disclose any protected health information of the patient. Copies may also be obtained at any time at our offices.

6. Any patient, guardian or personal representative has the right to object to the use of their health information for directory purposes.

7. Any patient, guardian or personal representative has the right to request to inspect and obtain copies of their medical record.

8. Any patient, guardian or personal representative has the right to request to inspect amendments be made to their medical record.

9. Any patient, guardian or personal representative has the right to request a six year accounting of all disclosures of their medical record. The history will be provided within 60 days of the request and a reasonable charge may be assessed for any copies after the first requested in a 12 month period.

10. Any patient, guardian or personal representative has the right to request restrictions as to how their health information may be used or disclosed to carry out treatment, payment or healthcare operations. The Practice is not required to agree to the restrictions requested, but if the Practice does agree, the Practice must abide by those restrictions.

11. Any person/patient may file a complaint to the Practice and to the Secretary of Health and Human Services if they believe their privacy rights have been violated. To file a complaint with the practice, please contact the Privacy Officer at the following address and/or phone number: Hemorrhoid Solutions, 300 Enterprise Dr., Suite E, Forest, VA 24551. Telephone 434-455-5505 and Fax 434-316-7008. All complaints will be addressed and the results will be reported to the Privacy Officer.

12. It is the policy of The Hemorrhoid Solutions that no retaliatory action will be made against any individual who submits or conveys a complaint of suspected or actual non-compliance of the privacy standards.