H I P A A

Notice of
Privacy Practices

*HIPAA: Health Insurance Portability and Accountability Act

Effective Date: April 14, 2003; rev. Dec. 1, 2003; rev. Dec. 1, 2004; rev. Nov. 1, 2005;
INFO 030463  CAT: 15-Patient Data  To reorder, log onto http://uvaprint.virginia.edu rev. Feb. 2006; rev. Apr. 2006; rev. Sept. 2010; rev. June 2013; rev. May 2018
 Name:

Medical Record Number:

1500002

Acknowledgement of Receipt of the HIPAA Notice of Privacy Practices

for the University of Virginia Health System

Federal law requires that we obtain your written acknowledgement of receipt of the UVA Notice of Privacy
Practices. Please sign below.

I acknowledge that I have received the UVA Notice of Privacy Practices.

Patient Name (Print):

Patient Date of Birth:

Legal Representative Name (Print) (if patient unable to sign):

Patient or Legal Representative Signature:

Date:

Please send completed forms to Health Information Services, University of Virginia Medical
Center, P.O. Box 800476, Charlottesville, VA 22908-0476

INFO 030463  CAT: 15-Patient Data  To reorder, log onto http://uvaprint.virginia.edu

 disclosure we will explain what we mean and give examples.
THIS NOTICE DESCRIBES HOW Not every use or disclosure in a category will be listed.
MEDICAL INFORMATION ABOUT YOU However, all of the ways we are permitted to use and
MAY BE USED AND DISCLOSED AND disclose information will fall within one of the categories.
HOW YOU CAN GET ACCESS TO THIS
INFORMATION. For Treatment. We may use medical information
about you to provide you with medical treatment or services.
PLEASE REVIEW IT CAREFULLY. We will provide medical information about you to doctors,
If you have any questions about this notice, please nurses, technicians, medical students, residents, or other
contact the Corporate Compliance and Privacy Office at personnel who are involved in taking care of you. For example,
434.924.2938. a doctor treating you for a broken leg may need to know if
you have diabetes because diabetes may slow the healing
This notice describes the priv­ process. In addition, the doctor may need to tell the dietician
Who Will Follow
acy practices of the University if you have diabetes so that we can arrange for appropriate
This Notice. of Virginia Health System, meals. Different departments of the Health System also
including the UVA Medical Center, UVA Continuum may share medical information about you in order to
Home Health Care and Infusion Services, the University coordinate the different things you need, such as prescriptions,
of Virginia Physicians Group, the University of Virginia laboratory work and x-rays. We may use and disclose
Transitional Care Hospital and: medical information about you in order to communicate
• Any health care professional authorized to enter with you about available treatment--for instance, to send
information into your medical record you appointment or prescription refill reminders, or to offer
• All departments, clinics and units wellness and other educational programs, or to tell you about
• Any member of a volunteer group we allow to help you or recommend possible treatment options or alternatives that
while you are a patient may be of interest to you.
• All Health System employees, staff and other personnel, We may also disclose medical information about
and students you to people outside the Health System who provide
• The Virginia Urologic Foundation, University of Virginia services that are related to your care, such as home health
Community Medicine LLC, and the University of agencies or medical equipment suppliers.
Virginia Imaging Center LLC.
The Medical Center inpatient psychiatric unit For Payment. We may use and disclose medical
gives patients a supplemental notice describing its practices. information about you so that the treatment and services
All of the above entities, sites and locations (the “Health you receive may be billed to and payment may be collected
System”) may share medical information with each other from you, an insurance company or another third party. For
for treatment, payment or operations purposes described example, we may need to give your health plan information
in this notice. about your surgery so your health plan will pay us or
reimburse you for the surgery. We may tell your health
Our Pledge We understand that medical plan about a treatment you are going to receive, to obtain
Regarding Medical information about you and prior approval or to determine whether your plan will cover
Information. your health is personal. We the rest of the treatment. If you do not want your health
are committed to protecting plan to receive information about treatment for which you
medical information about you. We create a record of the have paid in advance, see “Right to Request Restrictions”
care and services you receive. We need this record to on page 4 of this notice.
provide you with quality care and to comply with certain
legal requirements. This notice applies to all of the records For Health Care Operations. We may use and
of your care generated by the Health System, whether made disclose medical information about you for health care
by hospital personnel or your personal doctor. This notice operations. These uses and disclosures are necessary to run
will tell you about the ways in which we may use and the Health System and make sure that all of our patients
disclose medical information about you. We also describe receive quality care. For example, we may use medical
your rights and certain obligations we have regarding the information to review our treatment and services and to
use and disclosure of medical information. evaluate the performance of our staff in caring for you.
We are required by law to make sure that medical We may also combine medical information about many
information that identifies you is kept private; give you this patients to decide what additional services the Health
notice of our legal duties and privacy practices with respect System should offer, what services are not needed, and
to medical information about you; and follow the terms of whether certain new treatments are effective. We may also
the notice that is currently in effect. provide information to doctors, nurses, technicians, medical
and nursing students, and other personnel and trainees for
The following categories describe review and learning purposes. We may also combine the
How We May Use
different ways that we use and medical information we have with medical information
and Disclose Medical disclose medical information. from other hospitals to compare how we are doing and see
Information About You. For each category of use or where we can make improvements in the care and services
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we offer. We may remove information that identifies you Other Care Providers. We may disclose medical
from this set of medical information, so that others may information to health care professionals who have cared
use it to study health care and health care delivery without or currently are caring for you, such as rescue squads, a
learning who you are. referring hospital and its physicians, or a nursing home
medical director, for them to use in treating you, seeking
Business Associates. There are some services payment for treatment, and certain health care operations,
provided in our organization through contracts with business such as evaluating the quality of their care and the
associates. Examples include computer maintenance by performance of their staff, providing training, and licensing
outside companies and transcription of medical records and accreditation reviews.
by outside medical records services. Where these services
are contracted, we may disclose your health information to Research. Under certain circumstances, we
our business associates so that they can perform the job we may use and disclose medical information about you for
have asked them to do. Similarly, there are departments research purposes. For example, a research project may
of the University that provide services to us, and may need involve comparing the health and recovery of all patients
access to your health information to do their jobs. We who receive one medication to those who received another
require business associates and other UVA departments to for the same condition. We also may retain samples from
appropriately safeguard your information and to notify us tissue or blood and other similar fluids normally discarded
of any breaches to your health information. after a medical procedure, for later use in research projects.
All these research projects, however, are subject to a special
Fundraising Activities. We may use the following approval process. This process evaluates a proposed research
information to reach you in an effort to encourage project and its use of medical information, trying to
donations for the Health System. We also may disclose balance the research needs with patients’ need for privacy
this information to a foundation related to the Health of their medical information. Before we use or disclose
System so that the foundation may contact you to medical information for research, the project will have
encourage donations. This means your name, address, been approved through this research approval process. In
phone number and other contact information, age, gender, some cases, your authorization would be required. In other
insurance status, the names of your physicians, the dates
cases it would not, where the review process determines
you received treatment or services at the hospital, and the
that the project creates, at most, a minimal risk to privacy.
departments where you received treatment or services.
We may also disclose medical information about you to
It does not include information about your diagnosis or
people preparing to conduct a research project, for example,
treatment, except that we may use or disclose to a related
foundation limited information regarding the outcome of to help them look for patients with specific medical needs,
your treatment for screening purposes. You have the right so long as the medical information they review does not
to opt out of receiving contacts for fundraising. If you do leave the Health System. And if a research project can be
not want the hospital to contact you for fundraising efforts, done using medical data from which all the information
you may notify the Health System Development Office at that identifies you (such as your name and medical record
800.297.0102 or 434.924.8432. number) has been removed, we may use or release the data
without special approval. We also may use or release data
Inpatient Directory Information. Unless you for research with a few identifiers retained--dates of birth,
notify us that you object, we will use your name, location in admission and treatment, and general information about
the hospital, and general condition to respond to questions where you live (not your address), without special approval.
about you from persons who ask for you by name, if you However, in this case we will have those who receive the
are an inpatient. If you do not want some or all of this data sign an agreement to appropriately protect it.
information used for this purpose during your current
hospital stay, please notify the Bed Coordination Center As Required by Law. We will disclose medical
at 434.243.9931, or if you want to permanently restrict this information about you when required to do so by federal,
use, please notify the Admitting Office at 434.924.9231. state or local law.
This information and your religious affiliation also may
be provided to members of the clergy. If you do not want To Avert a Serious Threat to Health or Safety.
some or all of this information provided to members of the We may use and disclose medical information about you
clergy, please notify the Admitting Office at 434.924.9231. when necessary to prevent an immediate, serious threat to
your health and safety or the health and safety of the public
Individuals Involved in Your Care or Payment or another person. Any disclosure, however, would only be
for Your Care. We may release information about you to to someone able to help prevent the threat.
a family member or friend who is involved in your care,
or the payment for your care. We may tell your family or Organ and Tissue Donation. If you are an organ
friends your condition and that you are in the hospital. We donor, we may release medical information to organizations
may disclose medical information about you to an entity that handle organ or tissue procurement or to an organ
assisting in a disaster relief effort so that your family can be donation bank, to further organ or tissue donation and
notified about your condition, status and location. transplantation.
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 Military and Veterans. If you are a member of the or to have a copy sent to another person designated by
armed forces, we may release medical information about you. You may request copies of records in an electronic
you as required by military command authorities. We may format, and if the records are available in that format, they
also release medical information about foreign military will be provided in it. If they are not, we will provide an
personnel to the appropriate foreign military authority. alternate format. For medical records, you must submit a
signed authorization form to Health Information Services,
Workers’ Compensation. We may release medical University of Virginia Medical Center, P.O. Box 800476,
information about you for workers’ compensation or similar Charlottesville, VA 22908-0476, or by fax at 434.243.5995.
programs. These programs provide benefits for work- Authorization forms and instructions are available on the
related injuries or illness. Medical Center’s website at http://uvahealth.com/patients-
Public Health Risks. We may disclose medical visitors-guide/medical-records. Call 434-924.5136 with
information about you for public health activities. These any questions. For billing records you may write to Patient
activities generally include the following: Financial Services, P.O. Box 800750, Charlottesville, VA
• To prevent or control disease, injury or disability; 22908-0750, or call 800.523.4398. For physician bills, you
• To report births and deaths; may write to the University of Virginia Physicians Group
• To report endangering disabilities of drivers and pilots; at P.O. Box 9007, Charlottesville, VA 22906-9007, or call
• To report abuse or neglect of children, the elderly and 434.980.6110 or 800.868.6600. If you request a copy of
incompetent patients; the information, we may charge a fee for costs of copying
• To report reactions to medications or problems with and mailing.
products; to notify people of recalls of products they may
We may deny your request to inspect and copy
be using.
in certain very limited circumstances. If you are denied
Health Oversight Activities. We may disclose access to medical information, you may request that
medical information to a health oversight agency for the denial be reviewed. Another licensed health care
activities authorized by law. These oversight activities professional chosen by the hospital will review your request
include, for example, audits, investigations, inspections, and and the denial. The person conducting the review will not
licensure. These activities are necessary for the government be the person who denied your request. We will comply
to monitor the health care system, government programs, with the outcome of the review.
and compliance with civil rights laws.
Right to Amend. If you feel that medical
Lawsuits and Disputes. If you are involved in a information we have about you is incorrect or incomplete,
lawsuit or a dispute, we may disclose medical information you may ask us to amend the information. You have
about you in response to a court or administrative order. the right to request an amendment for as long as the
We may also disclose medical information about you in information is kept by or for the Health System. To request
response to a subpoena, discovery request, or other lawful an amendment, your request must be made in writing and
process by someone else involved in the dispute, but only submitted to Health Information Services, University of
if efforts have been made to tell you about the request or Virginia Medical Center, P.O. Box 800476, Charlottesville,
to obtain an order protecting the information requested. VA, 22908-0476. In addition, you must provide a reason
that supports your request. We may deny your request if
Law Enforcement. We may release medical you ask us to amend information that:
information if asked to do so by a law enforcement official:
• In response to a court order, subpoena, warrant, summons • Was not created by us, unless you can show the person or
or similar process; entity that created the information is no longer available
• About a death we believe may be the result of criminal to make the amendments; if so, we will add your request
conduct; to the information records;
• About criminal conduct at the hospital; and • Is not part of the medical information kept by or for the
• About wounds made by certain weapons. Health System;
• Is not part of the information which you would be per­
Medical Examiners and Funeral Directors. We mitted to inspect and copy; or
may release medical information to a medical examiner. • Is accurate and complete.
This may be necessary, for example, to identify a deceased
person or determine the cause of death. We may also release Right to an Accounting of Disclosures. You
medical information about deceased patients of the hospital have the right to request an “accounting of disclosures.”
to funeral directors as necessary to carry out their duties. This is a list of disclosures of medical information about
you that were not for treatment, payment, or health care
You have the following rights regarding medical information
operations and of which you were not previously aware.
we maintain about you:
Right to Inspect and Copy. To request this list of accounting of disclosures, you
Your Rights
You have the right to inspect must submit your request in writing to Health Information
Regarding Medical Services, University of Virginia Medical Center, P.O. Box
or receive a copy of your
Information About You. medical and billing records, 800476, Charlottesville, VA 22908-0476. Your request
3
must state a time period which may not be longer than com/patients-visitors-guide. To obtain a paper copy of
six years. Your request should indicate in what form you this notice, contact the Admitting Office at 434.924.9231.
want the list (for example, on paper or electronically). The
first list you request within a 12 month period will be free. We reserve the right to change this
For additional lists, we may charge you for the costs of Changes to notice, and make the changed notice
providing the list. We will notify you of the cost involved this Notice. effective for medical information we
and you may choose to withdraw or modify your request already have about you as well as any
at that time before any costs are incurred. information we receive in the future. We will post a copy of
the current notice in select registration and admission areas
Right to Request Restrictions. You have the and other key locations throughout the Health System,
right to restrict disclosure of health information to your and on our website. This notice will contain the effective
health plan for services paid out of pocket in full prior to date on the first page. In addition, each time you register
the service being provided. This restriction applies only if at or are admitted to the Health System for treatment or
the disclosure is to a health plan for purposes of payment or health care services as an inpatient or outpatient, we will
health care operations and the protected health information have copies of the current notice available on request.
relates to a health care item or service for which the health
care provider has been paid in full prior to the services. Talk If you believe your privacy rights have
to the clinic staff or your physician to exercise this right. Complaints. been violated, you may file a complaint
You have the right to request other restrictions on with the Health System or with the
our use or disclosure of medical information about you for Secretary of the Department of Health and Human
treatment, payment or operations purposes, or disclosure of Services. To file a complaint, contact the Corporate
health information about you to someone who is involved Compliance & Privacy Office at 434.924.2938. You will
in your care or the payment for your care. We are not not be penalized for filing a complaint.
required to agree to your request for these restrictions. For Other uses and disclosures of medical
instance, we will not be able to agree to requests that we Other Uses information not covered by this notice
cannot reasonably carry out, or that would interfere with of Medical or the laws that apply to us will be made
your treatment such as restricting your referring or primary
care physician’s access to your health information. Our
Information. only with your written permission (an
“authorization”). In particular, most
normal process is to immediately send records of your visit uses and disclosures of medical information for marketing
to your referring physician. purposes, most disclosures in return for payment, and most
Requests to restrict disclosures of health records to uses and disclosures of psychotherapy notes would require
other persons may be made by calling Health Information your authorization. If you give us permission to use or
Services at 434.924.5136. Requests to restrict disclosures disclose medical information about you for a particular
of Medical Center billing and payment records may be purpose, you may revoke that permission, in writing, at any
made by calling Patient Financial Services at 434.924.5377. time by contacting the Corporate Compliance & Privacy
Requests to restrict disclosure of physician billing and Office at 434.924.2938. If you revoke your permission, we
payment records may be made by calling the UVA will no longer use or disclose medical information about
Physicians Group at 434. 980.6134. If we agree, we will you for the reasons covered by your written authorization.
comply with your request unless the information is needed You understand that we are unable to take back any
to provide you emergency services. disclosures we have already made with your permission,
Right to Request Alternative Communications. and that we are required to retain our records of the care
You have the right to request that we communicate with that we provided to you.
you about medical matters in a certain way or at certain The Health System may collect your
locations. For example, you can ask that we only contact you Social
Security social security number. We use social
at work or by mail. To request alternative communications, security numbers for identification and
you must make your request in writing—contact the Numbers.
verifications (for example, to provide
Admitting Office at 434.924.9231 for instructions on how the right medical record when two patients have the same
to make your request. We will not ask you the reason for name). We also are required to collect social security
your request. We will accommodate all reasonable requests numbers by Virginia law (Va. Code 58.1-521) for use if
within our technical capabilities. Your request must specify needed in the administrative offset program. Some other
how or where you wish to be contacted. governmental programs, such as Medicaid, require social
Right to Receive Notice of Any Breach. You have security numbers. Providing a social security number is
the right to receive written notice from us if there has been voluntary, except for applicants to governmental programs
a breach of your identifiable health information. that require it. The privacy practices in the Notice apply to
your social security number.
Right to a Paper Copy of This Notice. You have
the right to a paper copy of this notice at any time. Even For more information, contact the
More Corporate Compliance & Privacy Office
if you have agreed to receive this notice electronically, you Information. at 434.924.2938.
are still entitled to a paper copy of this notice. You may
obtain a copy of this notice at our website, http://uvahealth.
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Nondiscrimination Notice

UVA Health System welcomes and provides services, If you believe that UVA Health System has failed
program and activities to all patients and visitors. to provide these services or discriminated in any
UVA Health System: way you can file a complaint in person or by mail,
fax or email with:
• C omplies with all applicable civil rights laws and
does not discriminate, exclude, or treat differently, Patient Experience Officer
patients or visitors on the basis of race, age, PO Box 800704
color, national origin, religion, disability, sexual Charlottesville, VA 22908-0704
orientation, gender, gender identity or gender 434.924.8315
expression. [email protected]

• P rovides free aids and services to allow people

with disabilities to communicate effectively You can file a civil rights complaint with the
with us, including: U.S. Department of Health and Human Services,
Office for Civil Rights. If you wish, we can help you.
• Qualified sign language interpreters
• Information in other formats (large print, audio, U.S. Department of Health and Human Services
accessible electronic formats, etc.) 200 Independence Avenue SW
• P rovides free language services in over 150 Room 509F, HHH Building
different languages to people whose primary Washington, D.C. 20201
language is not English, including: 800.368.1019
800.537.7697 (TDD)
• Qualified interpreters

• Information written in other languages Complaint forms, information and an online portal
for electronic filing are available at:
If you need communication aids or language hhs.gov/civil-rights/filing-a-complaint
services, call our Language Office at 434.982.1794.
INFO 93003 April 2018
UVA Health System will provide an
interpreter at no personal cost to you.

INFO 93003 Taglines April 2018

Language Assistance Services:

434.982.1794 (TTY: 844.346.7516)