OUR COMMITMENT TO YOUR PRIVACY:

Dr. Nabil Andrawis, Dr. Nashwa Gabra and our staff (the "Practice of Burke Internal Medicine, Inc."), is committed to maintaining the privacy of your protected health information ("PHI"). In conducting our business, we will create records regarding you and the treatment and services we provide to you. Your PHI includes information about your health condition and the care and treatment you receive from the Practice. The Practice is required by federal law to maintain the privacy of your PHI and to provide you with this Privacy Notice detailing the Practice's legal duties and privacy practices with respect to your PHI and may be required by State law to maintain greater restrictions on the use or release of your PHI than that which is provided for under federal law. In particular, the Practice is required to comply with the following State statutes: health General Article, Title 4, Subtitle 3, Confidentiality of Medical Records and Subtitle 4, personal Medical Records. The practice is required to abide by the terms of this Privacy Notice, reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for your entire PHI that it maintains, distribute any revised Privacy Notice to you prior to implementation and not retaliate against you for filing a complaint.

HOW THE PRACTICE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION (PHI):

The Practice, in accordance with this Notice and without asking for your consent or authorization may use and disclose your PHI for the purposes of: Treatment - To provide you with the health care you require, the Practice may use and disclose your PHI to those health care professionals, so that it may provide, coordinate, plan and manage your health care. Payment - To get paid for services provided to you, the Practice may provide your PHI, directly or through a business associate such as a billing service or a third party who may be responsible for your care, including insurance companies and health plans. Health Care Operations - To operate in accordance with applicable law and insurance requirements, the Practice may need to compile, use and disclose your PHI. Appointment Reminder - The practice 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. This may be done through a postcard or by phone. Family/Friends - The Practice may disclose to your family member, a close personal friend, or any other person identified by you, your PHI directly relevant to such person's involvement with your care or the payment for your care. The Practice may also use or disclose your PHI to notify or assist in the notification (including identifying or locating) a family member, a personal representative, or another person responsible for your care, of your location, general condition or death. However, in both cases if you are present at or prior to the use or disclosure of your PHI, the Practice may use or disclose your PHI if you agree, or if the Practice can reasonably infer from the circumstances, based on the exercise of its professional judgment that you do not object to the use or disclosure. If you are not present, the Practice will, in the exercise of professional judgment, determine whether the use or disclosure is in your best interest and, if so, disclose only the PHI that is directly relevant to the person's involvement with your care.

YOUR RIGHTS: You have the right to (All requests must be in writing):

• Revoke any Authorization or consent you have given to the Practice, at any time
• Request restrictions on certain uses and disclosure of your PHI including treatment, payment or healthcare operations as proved by law. Except in certain instances, the Practice may not be obligated to agree to any requested restrictions. In your written request, you must inform the Practice of what information you want to limit, whether you want to limit the Practice's use or disclosure, or both and to whom you want the limits to apply. If the Practice agrees to your request, the Practice will comply with your request unless the information is needed in order to provide you with emergency treatment.
• Receive confidential communication or PHI by alternative means or at alternative locations.
• Inspect and copy your PHI as provided by law the Practice can charge you a fee for the cost of copying, mailing or other supplies associated with your request. Our practice may deny your request to inspect and or copy in certain limited circumstances including psychotherapy notes and any information related to civil or criminal or administrative action.
• Amend your PHI as provided by law. You may ask to amend your health information if you believe it is incorrect or incomplete. You must provide a reason that supports your request. The Practice may deny your request. If you disagree with the Practice's denial, you will have the right to submit a written statement of disagreement and we may prepare a rebuttal to your statement and provide you with a copy of such rebuttal.
• Receive an accounting of disclosures of your PHI as provided by law. An "accounting of disclosures" is a list of certain non-routine disclosures our practice has made of you PHI for non-treatment or operation purposes. The request must state a time period, which may be longer than six (6) years and may not include dates before April 14, 2003. The request should indicate in what form you want the list (such as a paper or electronic copy). The first list you request within a twelve (12) month period will be free, but the Practice may charge you for the cost of providing additional lists. The Practice will notify you of the costs involved and you can decide to withdraw or modify your request before any costs are incurred.
• Receive a paper copy of this Privacy Notice from the Practice upon request to the Practice's Privacy Officer.
• Complain to the Practice or to the Secretary of Dept. of Health and Human Services, if you believe your privacy rights have been violated.

PATIENT ACKNOWLEDGEMENT

By subscribing my name below, I acknowledge receipt of a copy of this Notice, and my understanding and my agreement to its terms.

_____________________________________________________
Patient Signature (or Guardian if patient is a minor)

__________________________
Date

Burke Internal Medicine, Inc.
5631 Burke Centre Parkway
Suite A
Burke, VA 22015
(Near Fairfax, Virginia)
Tel: 703.250.5171
Fax: 703.250.5170
MAP & DIRECTIONS >>

Clinical Trials/Medical Research | Immigration Physicals | Flight Physicals | Hair Removal

Primary Care and Clinical Research Center in DC/Fairfax Area