Our Commitment To Your Privacy

We understand the importance of keeping your personal and health information secure and private. By following the Health Insurance Portability and Accountability Act of 1996 (‘HIPAA’), we maintain the privacy of your protected health information (‘PHI’; in written, verbal, and electronic form), provide you with notice of our legal duties and privacy practices with respect to your PHI, and abide by the terms of this notice. This notice informs you of your rights about the privacy of your PHI and how we may use and share your PHI. We ensure that your personal information is only used and shared in the manner described. If this notice is updated, changes will apply to PHI that we already have about you as well as any PHI that we may receive or create in the future. You may request a copy of our privacy practices at any time.

Patient Services, Inc.

Notice of Privacy Practices

This notice describes how personal and health information about you may be used and disclosed by PSI and how you can get access to this information. Please review it carefully.

Effective Date: September 26, 2014 Revision Date: June 15, 2019

If you have any questions about this notice, please contact our Privacy Officer at 1-800-366-7741. Written requests

may be made via email to [email protected] or to the address below:

Patient Services, Inc. Attn: Privacy Officer P.O. Box 5930 Midlothian, Virginia 23112

Our Commitment To Your Privacy

We understand the importance of keeping your personal and health information secure and private. By following the rules set forth by the Health Insurance Portability and Accountability Act of 1996 (‘HIPAA’), we maintain the privacy of your protected health information (‘PHI’) in written, verbal, and electronic form, provide you with notice of our legal duties and privacy practices with respect to your PHI, and abide by the terms of this notice. This notice informs you about your privacy rights and about how we may use and share your PHI. If this notice is updated, changes will apply to PHI that we already have about you as well as any PHI that we may receive or create in the future. You may request a copy of our privacy practices at any time.

Your Rights

When it comes to your PHI, you have certain rights.

For example, you have the right to:

  • Get a copy of your PSI Patient File
  • Correct your PSI Patient File
  • Request confidential communication
  • Ask us to limit the information we share
  • Get a list of those with whom we’ve shared your PHI
  • Get a copy of this privacy notice
  • Choose someone to act for you and/or have your PHI disclosed to them Request restrictions
  • File a complaint if you believe your privacy rights have been violated.

Getting a copy of your PSI Patient File

You can inspect and obtain a copy of your PSI Patient File. If you request it, we will provide you with a copy or a summary of your PSI Patient File, usually within 15 days. To do so, please submit your request in writing to our Privacy Officer at the address listed on the first page of this notice. We may charge a fee for the costs of copying, mailing, labor, and supplies related to your request depending upon local laws. If we maintain your PSI Patient File electronically, you may also request an electronic copy.

Asking us to correct your PSI Patient File

If you believe that any information in your PSI Patient File is incorrect or incomplete, you may ask us to amend it. To request an amendment, please submit your request in writing to our Privacy Officer at the address listed on the first page of this notice with a reason that supports your request. If we feel that your request is not correct, we may deny it and you may then submit a statement of disagreement. If we say “no” to your request, we’ll tell you why in writing within 60 days.

Requesting confidential communications

You can request that we communicate with you about your health and related issues in a certain way, or at a certain location. For example, you may ask that we contact you by mail, rather than telephone; or at work, rather than at home. Such a request must be made in writing to our Privacy Officer at the address listed on the first page of this notice. We will accommodate all reasonable requests, and we must say “yes” if you tell us that your safety would otherwise be in jeopardy.

Asking us to limit the information that we use or share

You have the right to request restrictions on certain uses and disclosures of your PHI but PSI is not legally required to agree to any such requested restriction. Please submit any restriction request in writing to our Privacy Officer at the address listed on the first page of this notice. In your request, you must tell us what information you want to limit and to whom you want the limitations to apply. We may say “no” to your request, but we’ll tell you why in writing.

Getting a list of those with whom we’ve shared your PHI

You can ask for a list (accounting) of the times we’ve shared your PHI for six years prior to the date you ask, who we shared it with, and why. To request such an accounting, please submit your written request to our Privacy Officer at the address listed on the first page of this notice. Your accounting will include all the disclosures made (except for those about treatment, payment, and health care operations, and certain other disclosures including those you asked us to make). We’ll provide one accounting per year for free, but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Getting a copy of this privacy notice

If you ask for a paper copy of this notice at any time, we will promptly give it to you free of charge (even if you have agreed to receive it electronically).

Choosing someone to act for you and/or have your PHI disclosed to them

If you have given someone medical ‘power of attorney’, or if someone is your legal guardian, that person is legally permitted to exercise your rights and make certain choices for you. Before we take any action based upon such a request, we will verify that the person has authority to act for you. You may also give verbal or written permission to have your PHI disclosed to another individual (such as a family member).

Filing a complaint if you feel your rights are violated

If you feel we have violated your rights, you can file a complaint with our Privacy Officer at the address listed on the first page of this notice. You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling

1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

How do we typically use or share your PHI?

We typically use or share your PHI in the following ways:

Helping to manage the health care treatment you receive

We can use your PHI and share it with professionals who are treating you. Example: A doctor sends us PHI about your diagnosis and treatment plan so we can arrange additional services.

Running our organization

We can use and disclose your PHI to run our organization and contact you when necessary. Example: We use PHI about you to develop better services for you.

A non-profit 501 (C ) (3) Patient Assistance Organization

Hours of Operation

8:30AM-5:00PM EST M/T/TH/F
9:30AM-5:00PM EST Wed
Closed from 12:30-1:30PM EST

Contact Us

Patient Services, Inc.
P.O. Box 5930
Midlothian, VA 23112
Fax: 1-804-744-9388

Phone: 1-800-366-7741