THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Effective Date: February 17, 2010
Fauquier Health
Notice of Privacy Practices

Understanding Your Health Record/Information

This notice (“Notice”) describes the practices of Fauquier Health, personnel, staff and any other health care provider* who may use or disclose your protected health information maintained at Fauquier Health in connection with your care. In addition, Fauquier Health and other health care providers may share medical information with each other for treatment, payments or health care operations described in this notice. We create a record of the care and services you receive as a patient of Fauquier Health. We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. This Notice applies to all of the records of your care as a patient of Fauquier Health.
This Notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

*I understand that the physicians and certain other providers participating in my care at Fauquier Health, including the physicians in the Emergency Department, are not employees or agents of Fauquier Health and are not acting for or on behalf of Fauquier Health. They are independent practitioners who are engaged in the private practice of medicine who have been granted privileges to use this facility for the care of their patients. I understand that all medical decisions regarding my treatment at Fauquier Health are made by such practitioners and not by Fauquier Health.

Your Health Information Rights

Although your health record is the physical property of Fauquier Health, you have certain rights with respect to these records. You have the right to:

• request a restriction on certain uses and disclosures of your information for treatment, payment, health care operations and as to disclosures permitted to persons, including family members involved with your care and as provided by law. However, we are not required by law to agree to a requested restriction, other than a request that we not disclose information to a health plan for payment of health care operations, and the information relates only to a health care item or service for which we have been paid in full;
• obtain a paper copy of this Notice;
• inspect and request a copy of your health record as provided by law;
• request that we amend your health record as provided by law. We will notify you if we deny your request to amend your health record;
• obtain an accounting of disclosures of your health information as provided by law;
• request communication of your health information by alternative means or at alternative locations. We will accommodate reasonable requests. You may exercise your rights set forth in this Notice by providing a written request, except for requests to obtain a paper copy of the notice, to the Health Information Management Department at Fauquier Health, 500 Hospital Drive, Warrenton, Virginia 20186.

Our Responsibilities

In addition to the responsibilities set forth above, we are also required to:

• maintain the privacy of your health information as provided by law;
• provide you with a notice as to our legal duties and privacy practices with respect to information we maintain about you;
• abide by the terms of the notice currently in effect.
• We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain, including information created or received before the change. Should our information practices change, we will have the revised notice available for you to request at Fauquier Health’s web page at www. Fauquierhospital.org.
• We will not use or disclose your health information without your written authorization, except as described in this Notice or the notice in effect at the time of the use or disclosure.

Examples of Disclosures for Treatment, Payment, HealthCare Operation and as Otherwise Allowed by Law

The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information should fall within one of the categories.

We will use and disclose your health information for treatment.
For example: We may disclose medical information about you to doctors, nurses, technicians, medical students, trainees or other personnel who are involved in taking care of you. We may share medical information about you in order to coordinate different treatments, such as prescriptions, lab work and x-rays. We may also provide your physician or subsequent health-care provider with copies of various reports to assist in treating you once you are discharged from care.

We will use and disclose your health information for payment.
For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures and supplies used.

We will use your health information for health care operations
For example: We may use and disclose information to evaluate services you receive to ensure that our patients receive quality care and to ensure that we continue to earn professional accreditation.

We will use your health information as otherwise allowed by law.
The following are some other examples of how we may use or disclose medical information about you and purposes for which we may use or disclose your information.

Business associates: There are some services we carry out through contracts with business associates. Examples include Patient Satisfaction Surveyors and copy services. We may disclose your health information to business associates, but unless the disclosure is made to a health care provider, we will generally have entered into a formal agreement with the business associate requiring business associates to appropriately safeguard your information.

Directory: Unless you notify us that you object, we will use your name, location in facility and religious affiliation for directory purposes while you are a patient at Fauquier Health. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name.

Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative or another person responsible for your care, your location and general condition.

Funeral directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties.

Communication for treatment and health care operations: We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you.

Averting threats: We may use and disclose information to prevent a serious threat to the health and safety of the public or an individual.

Fund-raising: We may use certain information (name, address, dates of service, age, and gender) to contact you in the future to raise money for Fauquier Health. We may also provide this name to our institutionally related foundation, for the same purpose. The money raised will be used to expand and improve the services and programs we provide the community.

Workers’ compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs established by law.

Organ donation: If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank.

Public health activities/oversight: We may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability or maintaining birth and death records. We also may disclose information to health oversight agencies authorized by law.

Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military command authorities.

Abuse, neglect or domestic violence: As required by law, we may disclose health information to a governmental authority authorized by law to receive reports of abuse, neglect or domestic violence.

Judicial, administrative and law enforcement purposes: Consistent with applicable law, we may disclose health information about you for judicial, administrative and law enforcement purposes. This may include information for intelligence and national security purposes and for protective services for governmental officials.

Required or allowed by law: We will disclose medical information about you when required or allowed to do so by federal, state or local law.

For More Information or to Report a Problem

If you have questions and would like additional information, you may contact the Fauquier Health Patient Advocate at 540-316-5014.
If you believe your privacy rights have been violated, you can file a complaint with the Fauquier Health Privacy Officer at 540-316-4442 or with the U.S. Secretary of Health and Human Services. There will be no retaliation for filing a complaint.