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.

Your Rights

We can answer your questions about privacy practices, accept any complaints you might have, and help you file a complaint.

Get an electronic or paper copy of your medical record: You can ask to see, obtain, or have sent to someone else, a copy of your medical record.  If you are requesting a personal copy of your records, I may ask to review your records with you.  I will provide a copy or a summary of your health information, usually within two weeks of your written request.  I will charge a reasonable, cost-based fee. Please remember that electronic media is not always safe from unauthorized access and your confidentiality cannot be guaranteed in these circumstances.

Ask to correct your medical record: You can ask me to correct health information about you that you think is incorrect or incomplete.

Request confidential communications: You can ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address.  Mohammad will agree to all reasonable requests.

Ask to limit what we use or share: I do not sell your personal information, nor use it for marketing.  Except for the disclosures listed below, I does not share your information, including psychotherapy notes, without a signed release of information that allows me to do so. You are allowed to retract that request at any time to stop any future disclosure of your information.  Further, you can ask me to limit, or not use, certain health information for treatment, payment, or business operations (data collection, auditing, etc.).  I am not required to agree to this request if it would affect your care. If you pay for a service or health care item out-of-pocket in full, I will not disclose that information to your health insurer, unless required to do so by law.

Get a list of those with whom your information is shared: You can ask for a list (accounting) of the times I have shared your health information for up to six years prior to the date you ask, with whom I shared the information and why.  I will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make).  This request will need to be submitted in writing and may take up to 60 days to fulfill the request.

Get a copy of this privacy notice: You have the right to receive copies of this notice electronically.

Choose someone to act for you: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.  I will make sure the person has this authority and can act for you before I take any action, within the limits of the law.

File a complaint if you feel your rights are violated: You can file a complaint if you feel I have violated your rights with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints or by contacting the Virginia Department of Health Professions at http://www.dhp.virginia.gov  or (800) 533-1560.  You will not be retaliated against for filing a complaint.

For the most up to date information please contact our office