Effective Date:  April 14, 2003

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. 

Understanding Your Health Record/Information 

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made.  Typically, this record contains your symptoms, examination and test results, diagnoses, treatment and a plan for future care or treatment.  This information, often referred to as your health or medical record, serves as a: 

bullet basis for planning your care and treatment
bullet means of communication among the many health professionals who contribute to your care
bullet legal document describing the care you received
bullet means by which you or a third-party payer can verify that services billed were actually provided
bullet a tool in educating health professionals
bullet a source of data for medical research
bullet a source of information for public health officials charged with improving the health of the nation
bullet a source of data for facility planning and marketing
bullet a tool with which we can assess and continually work to improve the care we render and the outcomes we achieve
bullet Understanding what is in your record and how your health information is used helps you to:

         ensure its accuracy

         better understand who, what, when, where, and why others may access your health information

         make more informed decisions when authorizing disclosure to others 

Your Health Information Rights 

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you.  You have the right to: 

bullet request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522
bullet obtain a paper copy of the notice of information practices upon request
bullet inspect and copy your health record as provided for in 45 CFR 164.524
bullet amend your health record as provided in 45 CFR 164.528
bullet obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528
bullet request communications of your health information by alternative means or at alternative locations
bullet revoke your authorization to use or disclose health information except to the extent that action has already been taken

Our Responsibilities 

This organization is required to: 

bullet maintain the privacy of your health information
bullet provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
bullet abide by the terms of this notice
bullet notify you if we are unable to agree to a requested restriction
bullet accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain.  Should our information practices change, we will mail a revised notice to the address you have supplied us. 

We will not use or disclose your health information without your authorization, except as described in this notice. 

For More Information or to Report a Problem 

If you have questions and would like additional information, you may contact the director of health management information at: 

Office for Civil Rights

Department of Health and Human Services

150 South Independence Mall West

Public Ledger Building, Suite 372

Philadelphia, Pennsylvania 19106-9111

Main Line (215) 861-4441

Hotline (800) 368-1019

TDD (215) 861-4440

Fax (215) 861-4431 

Complaints: If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services.  To file a complaint with the Practice, you must submit complaint in writing to our Privacy Officer at:

Vijayalakshmi Selvaraj, M.D., F.A.A.P

851 Evans City Road

Renfrew, Pennsylvania 16053

  You will not be retaliated against for filing a complaint. 

Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You my view an electronic copy of this notice on our website,  To obtain a paper copy of this notice, you may ask for a copy at registration when you visit the Practice for services, or you may contact our Privacy Officer.  If we make any changes to this notice, we will provide you with a updated notice as well as post it on our website.

Examples of Disclosures for Treatment, Payment and Health Operations 

We will use your health information  for treatment. 

For example:  Information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you.  Your physician will document in your record his or her expectations of the members of your healthcare team.  Members of your healthcare team will then record the actions they took and their observations.  In that way, the physician will know how you are responding to treatment. 

We will also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you are discharged from this hospital. 

We will use 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 regular health operations. 

For example:  Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it.  This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide. 

Business Associates: There are some services provided in our organization through contacts with business associates.  Examples include physician services in the emergency department and radiology, certain laboratory tests, and a copy service we use when making copies of your health record.  When these services are contracted, we may disclose your health information to our business associate so that it can perform the job we have asked it to do and bill you or your third-party payer for services rendered.  However, to protect your health information we require the business associate to appropriately safeguard your information. 

Directory: Unless you notify us that you object, we will use your name, location in the facility, general condition and religious affiliation for directory purposes.  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. 

Communication with family: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that personís involvement in your care or payment related to your care. 

Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. 

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

Organ procurement organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant. 

Marketing: 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. 

Fund-raising: We may contact you as part of a fund-raising effort. 

Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement. 

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. 

Public health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability. 

Correctional institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals. 

Law enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. 

Medical equipment vendor:  At various times, the patient may request a medical equipment vendor to be contacted on his/her behalf.  If a medical equipment vendor is contacted by the practice of Dr. Viji Selvaraj, M.D. on behalf of the patient, protected health information may be discussed.  

Federal law makes provisions for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public. 

QuestionsFor further information about matters covered by this notice you may contact our Privacy Officer at the above address or by telephone at: (724) 789-9950 

Learn what HIPAA is all about

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