Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.
PWNC Patient Privacy
PWNC Pledge Regarding Medical Information
We are required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to: Make sure that health information that identifies you is kept confidential.
How We May Use and Disclose Health Information about You
To Provide Treatment We may use health information about you to provide you with medical treatment and services. Your health information may be disclosed to doctors, nurses and employees involved in your medical care. Your information can be shared with these caregivers during episodes of treatment.
To Obtain Payment We may disclose health information about you so that treatment and services may be authorized and bills may be sent and monies collected from your insurance company. This information may be released via paper, fax, or electronic transmission.
Appointment Reminders Or Request Responses We may use and disclose information to contact you as a reminder that you have an upcoming appointment for an office visit or test. Likewise when responding to your requests concerning lab results or prescription requests, we may leave a message at your home, voice mail, or with your permission your office. We may share information with a family member or caregiver who is involved in your care, with your permission.
Other Uses of Medical Information If you have given us permission to disclose your medical information, in writing, and decide you no longer want your information disclosed, you may revoke this permission in writing. At that time we will no longer disclose medical information about you for the reasons covered by your written authorization. We are required to retain our medical records concerning the care we have provided you. As a parent or guardian, you have the right to make the decision regarding your child’s medical information.
Your Rights Regarding Medical Information about You
You have the right to inspect and receive a copy of your medical records. To inspect your records, you must make an appointment with the Privacy Officer. This usually takes about 2 weeks, as she has other duties, and this would have to take place outside patient care hours. If you request a copy of your medical records, there is a fee, and usually a two week turn around period.
You have a right to request an amendment if you feel the information about you is incorrect or incomplete. This must be done in writing and submitted to our Privacy Officer. There must be a valid reason for such a request. The request for this amendment may be denied. This is left to the discretion of the treating physician.
Changes to this Notice
We reserve the right to make changes to this notice. We reserve the right to make the changes effective for medical information we already have about you as well as any future information we receive.
If you believe that your rights have been violated or the PWNC is not in compliance with these privacy rights, you may file a complaint with the Privacy Officer for PWNC. This must be done in writing. Include these points:
- The name of the facility associated with PWNC
- A description of the acts that you believe led to a violation of your medical privacy.
All complaints will be investigated.
Prince William Neuroscience Center (PWNC)
8650 Sudley Road Suite 300
Manassas, VA 20110
In compliance with the Government Health Information Portability and Accountability Act (HIPAA), our ethics and privacy promise to our patients is that your personal health information (PHI) is kept in strict confidence. Your PHI will not be disclosed or given out without your permission. Your medical notes are forwarded to your referring physician, and to any other medical care provider that you sign a release for, at no cost.
In compliance with HIPAA regulations, we must have your written permission to leave messages at your home or place of employment, e.g. PWNC has my permission to contact all health care providers sharing in my medical care.
PWNC does not file claims with attorneys or auto insurance. Claims will be filed with health insurance only. If you do not have health insurance and are working with an attorney, payment is due in full at time of service. A $50.00 charge is required for records handling for private use, and for an attorney or insurance company. No personal injury legal assignments will be considered.