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Effective Date: September 1, 2013


This Notice will tell you about the ways in which Charlottesville Pathology Associates, P.L.C. ("CPA") protects, use and discloses your protected health information ("PHI"). This Notice also describe your rights and certain obligations we have regarding the use and disclosure of PHI. If you have any questions about this Notice of Privacy Practices ("Notice"), please contact CPA's Privacy Officer, Thomas H. Dudley, Jr., at Charlottesville Pathology Associates, PLC, 500 Martha Jefferson Drive, Charlottesville, VA 22911, telephone (434) 654-7170.

PHI means any information, transmitted or maintained in any form or medium, which CPA creates or receives that relates to your physical or mental health, the delivery of health care services to your or payment for health care services and that identifies you or could be used to identify you. We maintain your PHI in a record we create of the services and items you receive from CPA. This Notice applies to all of those records of created, received or maintained by CPA.

We are required by law to make sure that PHI is kept private; give you this Notice of our legal duties and privacy practices with respect to your PHI; and comply with the currently effective terms of this Notice.


The following categories describe different ways that we use and disclose PHI.

Use for Treatment. Payment, or Health Care Operations

We are permitted to use and disclose your PHI (1) to treat you by providing medical and similar services, (2) to be paid or request payment for our services, and (3) to conduct health care operations. This section of this Notice discusses each of these types of uses and disclosures of PHI.

  • For Treatment. We may use PHI about you to provide you with health care treatment or services. For example, we may use your PHI to provide medical services to you. We may disclose PHI about you to CPA personnel, as well as to doctors, nurses, hospitals, clinics or other health care providers who are involved in your care. For example, a doctor treating you for a particular clinical condition may need to know the results of pathology services that have been provided to you. CPA may also share PHI about you in order to coordinate health care services and items that you may need.

  • For Payment. We may use and disclose PHI about you so that the services and items that you receive from CPA may be billed to and payment may be collected from you, an insurance company, or a third party payor. For example, we may need to give your health plan information about the services or items that you received so that your health plan will pay us or reimburse you for the services or items.

  • For Health Care Operations. We may use and disclose PHI about you for health care operations. These uses and disclosures are necessary to make sure you receive quality care. For example, we may use PHI to review our treatment and services and to evaluate the performance of our staff in providing services to you.

Other Uses and Disclosures of PHI

Listed below are a number of other ways that CPA is permitted or required to use or disclose PHI. This list is not exhaustive. Therefore, not every use or disclosure in a category is listed.

  • Individuals Involved in Your Care or Payment for Your Care. We may release PHI about you to a friend or family member who is involved in your clinical care. We may share PHI about you with family members who accompany you for services. We may also give information to someone who helps pay for your care. In addition, we may disclose PHI about you to a person or entity assisting in an emergency so that your family can be notified about your condition, status and location.

  • As Required By Law. We will disclose PHI about you when required to do so by federal, state, or local law.

  • Public Health Risks. We may disclose PHI about you for public health activities.

  • Health Oversight Activities. We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure.

  • Lawsuits and Disputes. If you are involved in a lawsuit or dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

  • Law Enforcement. We may release PHI if asked to do so by a law enforcement official as permitted by law.

  • To Avert a Serious Threat to Health or Safety. We may use and disclose PHI about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

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

  • Health-Related Benefits and Services. We may use and disclose PHI to tell you about health-related benefits or services that may be of interest to you.

  • Workers' Compensation. We may release PHI about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Other uses and disclosures will be made only upon your written authorization. You also have the right to revoke such authorization, in writing, except where we have previously taken action in reliance on your prior authorization or if the authorization was a condition to obtaining insurance or health plan coverage and applicable law provides the insurer or health plan with the right to contest a claim under the policy.


You have the following rights with respect to your PHI:

Right to Inspect and Copy. You have the right to inspect and copy PHI that may be used to make decisions about your care. Generally, this information includes health care and billing records, but does not include (1) psychotherapy notes; (2) information prepared in anticipation of or for use in, a civil, criminal, or administrative action; and (3) PHI maintained by a covered entity that is (a) subject to the Clinical Laboratory Improvements Amendments ("CLIA") of 1988, 42 U.S.C. 263a, if access to the individual would be prohibited by law, or (b) exempt from CLIA pursuant to 42 CFR 493.3(a)(2).

To inspect and copy PHI maintained by CPA, you must submit your request in writing to CPA's Privacy Officer. We may charge a fee for the costs of copying, mailing or other supplies associated with you request. We may deny your request to inspect and copy your PHI in certain limited circumstances. If you are denied access to PHI, you will receive a written denial. You may request that the denial be reviewed. Thereafter, a licensed health care provider chosen by CPA will review your request and the denial. The person conducting the review will not be the person who originally denied your request. We will comply with the outcome of the review.

We may charge you reasonable fees for copying your PHI.

Right to Amend. If you believe that the PHI we have about you is inaccurate or incomplete, you may ask us to amend the information. You have the right to request an amendment for so long as the information is kept by CPA. To request an amendment to your PHI, your request must be made in writing and submitted to CPA's Privacy Officer. In addition, you must provide a reason that supports your request. We will generally make a decision regarding your request for amendment no later than 60 days after receipt of your request. However, if we are unable to act on the request within this time, we may extend the time for 30 more days but we will provide you with a written notice of the reason for the delay and the approximate time for completion. If we deny your requested amendment, we will provide you with a written denial.

We have the right to deny your request for an amendment if it is not in writing or does not include a reason to support the request. We are not required to agree to your request if you ask us to amend PHI that was not created by us, unless the person or entity that created the information is no longer available to make the amendment; is not part of the PHI kept by or for CPA; is not part of the PHI which you would be permitted to inspect and copy; or is already accurate and complete.

Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured Protected Health Information.

Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of Health Information for purposes other than treatment, payment and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to Charlottesville Pathology Associates at 500 Martha Jefferson Drive, Charlottesville, VA 22911. .

Right to Request a Restriction of Protected Health Information. You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to Charlottesville Pathology Associates at 500 Martha Jefferson Drive, Charlottesville, VA 22911. We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

Right to Request Confidential Communications. You also have the right to request that we communicate with you about health care matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make you request in writing to CPA's Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. You request must specify how or where you wish to be contacted.

Right to Receive Notice Electronically. You have the right to a paper copy of this Notice. You may ask us 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. To obtain a paper copy of this notice, please write to or call CPA's Privacy Officer.

We reserve the right to change our privacy practices that are described in this Notice. We reserve the right to make the revised or changed privacy practices applicable to PHI we already have about you as well as any information we receive in the future. A copy of our current Notice will be posted as required by the Privacy Rules. Prior to a material change to the uses or disclosures, your rights, our legal duties, or other privacy practices stated in this Notice, we will promptly revise and distribute the Notice. The Notice will contain the effective date on the first page. We will post current updated copy of this notice on our website, WWW.CVILLEPATHOLOGY.NET.

If you believe your privacy rights have been violated, you may file a complaint with CPA or with the Secretary of the Department of Health and Human Services. To file a complaint with CPA, write to CPA's Privacy Officer. All complaints must be in writing. You will not be penalized or retaliated against for filing a complaint.

Other uses and disclosures of PHI not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you provide us permission to use or disclose PHI about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose PHI about you for the reasons covered by your written authorization. You understand that we are unable to retract any disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provided to you.

I acknowledge receipt of Charlottesville Pathology Associates' Notice of Privacy Practices.

Date: _________________________

________________________________Signature of Patient Or Legal Representative

________________________________Printed Name

________________________________Relationship of Legal Representative to Patient

The patient or the patient's legal representative did not provide a written acknowledgment of receipt of this Notice of Privacy Practices. The following explains the good faith efforts to obtain the written acknowledgment and the reasons why the acknowledgment was not obtained: