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.

NOTICE OF INFORMATION PRACTICES

Behavioral Awareness Center, P.C. is dedicated to protecting your medical information. We are required by law to maintain the privacy of protected health information and to provide you with this Notice of our legal duties and privacy practices with respect to protected health information. Behavioral Awareness Center, P.C. is required by law to abide by the terms of this Notice.

1. Behavioral Awareness Center, P.C. may use and disclose protected health information for treatment, payment and healthcare operations. Examples of these include, but are not limited to, requested preschool or 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 and collection agencies. Healthcare operations include, but are not limited to, internal quality control and assurance including auditing of records.

2. Behavioral Awareness Center, P.C. 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. Behavioral Awareness Center, P.C. 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. Behavioral Awareness Center, P.C. will abide by the terms of this notice currently in effect at the time of the disclosure.

5. Behavioral Awareness Center, P.C. 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. Behavioral Awareness Center, P.C. 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 known 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 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: Behavioral Awareness Center, P.C., 681 Hioaks Road, Suite A, Richmond, VA 23225, Telephone 804-320-3626, Fax 804-330-5567. All complaints will be addressed and the results will be reported to the Privacy Officer.

12. It is the policy of Behavioral Awareness Center, P.C. 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.

Disclaimer: Contents are informational and not intended as legal advice. NCRIC MSO, Inc. and its subsidiaries, its employees, agents and staff, make no representation, guarantee or waranty, express or implied, that these forms are error-free or that the use of this information will prevent differences of opinion or disputes with any other party, and will bear no responsibility or liability for the results or consequences of its use.