The Pavilion at Williamsburg Place


Health Insurance Portability and Accountability Act of 1996 (HIPAA)


What is “Protected Health Information” or “PHI”?
“Protected health information,” or “PHI” for short, is information that identifies who you are and relates to, your past, present, or future physical or mental health or condition; the provision of health care to you, or past, present; or future payment for the provision of health care to you.  PHI does not include information about you that is publicly available, or that is in a summary form that does not identify who you are.  If you are an employee of our participating physician’s office, PHI does not include your health information in your personnel file.

Purpose of this Notice
In the course of doing business, we gather and maintain PHI about our members.  We respect the privacy of your PHI and understand the importance of keeping this information confidential and secure.  This Notice describes our privacy practices and how we protect the confidentiality of your PHI.  We are obligated to maintain the privacy of your PHI by implementing reasonable and appropriate safeguards.  We are also obligated to explain to you by this Notice about our legal obligations to maintain the privacy of your PHI.  We must follow our Notice that is currently in effect.

How We Protect Your PHI
We restrict access to your PHI to those employees who need access in order to provide services to our members.  We have established and maintain appropriate physical, electronic and procedural safeguards to protect your PHI against unauthorized use or disclosure.  We have established a training program that our employees must complete and update annually and have an established Compliance Office which has overall responsibility for developing, training and overseeing the implementation and enforcement of policies and procedures to safeguard your PHI against inappropriate access, use and disclosure.

Types of Use and Disclosure of PHI We May Make Without Your Authorization
Treatment; Payment; Health Care Operations
Federal and state law allows us to use and disclose your PHI in order to provide health care services to you, as well as to bill and collect payments for the health care services provided to you by our participating physicians.  For example, we may use your PHI to authorize referrals to specialists and to review the quality of care provided by your participating physician.  We may disclose your PHI to health plans or other responsible parties to receive payment for the services provided to you by our participating physicians.

We may also use or disclose your PHI, for example, to recommend to you treatment alternatives, to inform you about health-related benefits and services that we offer, or to contact you to remind you of your appointments.  We conduct these activities to provide health care to you, and not as marketing.

Federal and state law also allows us to use and disclose your PHI as necessary in connection with our health care operations. For example, we may use your PHI for resolution of any grievance or appeal that you file if you are unhappy with the care you have received.  We may also use your PHI in connection with population-based disease management programs.  We may use or disclose your PHI to perform certain business functions to our business associates, who must also agree to safeguard your PHI as required by law.

We are also allowed by law to use and disclose your PHI without your authorization for the following purposes:

1. When required by law – In some circumstances, we are required by federal or state laws to disclose certain PHI to others, such as public agencies for various reasons;
2. For public health activities – Such as reports about communicable diseases, defective medical devices to the FDA or work-related health issues;
3. Reports about child and other types of abuse or neglect, or domestic violence;
4. For health oversight activities – Such as reports to governmental agencies that are responsible for licensing physicians or other health care providers;
5. For lawsuits and other legal disputes – In connection with court proceedings or proceedings before administrative agencies, or to defend us or our participating physicians in a legal dispute;
6. For law enforcement purposes –Such as responding to a warrant, or reporting a crime;
7. Reports to coroners, medical examiners, or funeral directors – To assist them in performance of their legal duties;
8. For tissue or organ donations – To organ procurement or transplant organizations to assist them;
9. For research – To medical researchers with an approval of an institutional review board (IRB) or privacy board that oversees studies on human subjects.  Researchers are also required to safeguard your PHI;
10. To avert a serious threat to the health or safety of you or other members of the public;
11. For national security and intelligence/military activities – Such as protection of the President or foreign dignitaries; and
12. In connection with services provided under workers’ compensation laws.

We may not disclose your PHI to your family members or other persons unless we have your authorization to do so.  However, we may disclose your PHI to your family members or others who help pay for your care.  We may also notify disaster relief organizations to assist them with their relief efforts.  When you are a patient at a hospital or medical facility with which we are affiliated, we may create a directory that includes your name, your location at the facility, your general condition and your religious affiliation. 

There are some types of PHI, such as HIV test results or mental health information, which are protected by stricter laws.  However, even such PHI may be used or disclosed without your written authorization if required or permitted by law.

All other uses and disclosures of your PHI must be made with your written authorization.

If you need an authorization form, we will send you one for you or your personal representative to complete.  When you receive the form, please fill it out and send it to the following address:

The Pavilion at Williamsburg Place
5483 Mooretown Road
Williamsburg, VA 23188

You may revoke or modify your authorization at any time by writing to us at the same address.  Please note that your revocation or modification may not be effective in some circumstances, such as when we have already taken action relying on your authorization.

Your Rights Regarding Your PHI
Right to Inspect and Copy to Your PHI
You have the right to review and copy your PHI we maintain.  Usually this includes medical and billing information, but does not include psychotherapy notes.  If you wish to access to your PHI, you must submit your request in writing to us.  We will respond to your request and tell you when and where you can review your PHI in our possession within our normal business hours.  If you would like a copy of the information we have, please write to us at the same address.  If we provide you with a copy, we may charge a reasonable administrative fee for copying your PHI to the extent permitted by applicable law.  If we deny your request for review or copy of your PHI, we will explain the reason in writing.
Right to Amend Your PHI
If you believe that medical information we have about you is incorrect or incomplete, you have the right to request an amendment.

To request an amendment, your request must be in writing and submitted to us.  In addition, you must provide a reason that supports your request.  We will attach your addendum to the record(s) of your PHI. Your amended PHI will be available for your review upon written request.

In addition, we may deny your request if you ask us to amend information that:
• was not created by us, unless the person or entity that created the information is no longer available to respond to the amendment;
• is not part of the medical information kept by or for us;
• is not part of the information which you would be permitted to inspect and copy; or
• is accurate and complete.
Right to Receive an Accounting of Disclosures of Your PHI
You have the right to request an accounting of certain disclosures that we make of your PHI.  You can request an accounting by writing to us.  Please note that certain disclosures, such as those made for treatment, payment, or health care operations, need not be included in the accounting we provide to you.  We will respond to your request within a reasonable period of time, but no later than 60 days after we receive your written request.

Right to Receive a Copy of This Notice
You have the right to request and receive 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.
You may obtain a copy of this notice at our website,
To obtain a paper copy of this notice, make request from admitting and/or registration
Right to Request Restrictions
You have the right to request restrictions on how we use and disclose your PHI for our treatment, payment, and health care operations.  All requests must be made in writing.  Upon receipt, we will review your request and notify you whether we have accepted or denied your request.  Please note that we are not required to accept your request for restrictions.  Your PHI is critical for providing you with quality health care.  We believe we have taken appropriate safeguards and internal restrictions to protect your PHI, and that additional restriction may be harmful to your care.
Right to Confidential Communications
You have the right to request that we provide your PHI to you in a confidential manner.  For example, you may request that we send your PHI by an alternate means (e.g., sending by a sealed envelope, rather than a post card) or to an alternate address (e.g., calling you at a different telephone number, or sending a letter to you at your office address rather than your home address).  We will accommodate any reasonable requests, unless they are administratively too burdensome, or prohibited by law.
Right to Complain
We must follow the privacy practices set forth in this Notice while in effect.  If you have any questions about this Notice, wish to exercise your rights, or file a complaint; please direct your inquiries to:

Corporate Compliance Officer
Diamond Healthcare Corporation
P.O. Box 85050
Richmond, VA 23285-5050

You also have the right to directly complain to the Secretary of the United States Department of Health and Human Service.  All complaints must be submitted in writing. 


Rights Reserved
We will use and disclose your PHI to the fullest extent authorized by law.  We reserve the rights as expressed in this Notice.  We reserve the right to revise our privacy practices consistent with law and make them applicable to your entire PHI that we maintain, regardless of when it was received or created.  If we make material or important changes to our privacy practices, we will promptly revise our Notice.  Unless law requires the changes, we will not implement material changes to our privacy practices before we revise our Notice.  You may request updates to this Notice at any time.

Effective Date
The effective date of this Notice is April 1, 2012.


Corporate Compliance Officer
Diamond Healthcare Corporation
P.O. Box 85050
Richmond, VA 23285-5050

As a recipient of Federal financial assistance, The Pavilion at Williamsburg Place (The Pavilion) does not exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin, disability, or age in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, whether carried out by The Pavilion directly or through a contractor or any other entity with which The Pavilion arranges to carry out its programs and activities.

This statement is in accordance with the provisions of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Regulations of the U.S. Department of Health and Human Services issued pursuant to these statutes at Title 45 Code of Federal Regulations Parts 80, 84, and 91.

In case of questions, please contact:

The Pavilion at Williamsburg Place
Contact Person/Section 504 Coordinator:        Patty Cranford
Telephone Number:                                     757.941.6400
TDD/State Relay Number:                             800.828.1120


The Pavilion will take appropriate steps to ensure that persons with disabilities, including persons who are deaf, hard of hearing, or blind, or who have other sensory or manual impairments, have an equal opportunity to participate in our services, activities, programs and other benefits. The procedures outlined below are intended to ensure effective communication with patients involving their medical conditions, treatment, services, and benefits. The procedures also apply, among other types of communication, communication of information contained in important documents, including consent to treatment forms, financial and insurance benefits forms, etc. All necessary auxiliary aids and services shall be provided without cost to the person being served.

All staff will be provided written notice of this policy and procedure, and staff that may have direct contact with individuals with disabilities will be trained in effective communication techniques, including the effective use of interpreters.

   1.    Identification and assessment of need:

The Pavilion provides notice of the availability of and procedure for requesting auxiliary aids and services through notices in our brochures and patient handbooks and through notices posted in the lobby and intake/admission offices. When an individual self identifies as a person with a disability that affects the ability to communicate or to access or manipulate written materials or requests an auxiliary aid or service, staff will consult with the individual to determine what aids or services are necessary to provide effective communication in particular situations.

   2.    Provision of Auxiliary Aids and Services:

          The Pavilion shall provide the following services or aids to achieve effective
          communication with persons with disabilities:

All Persons Who Are Deaf or Hard of Hearing

  • For persons who are deaf/hard of hearing and who sign language as their primary means of communication, The Executive Director is responsible for providing effective interpretation of arranging for a qulaityifes interpreter when needed.

  • In the event that an interpreter is needed, the Executive Director is responsbile for:

    • Maintaining a list of qualified interpreters on staff showing their names, phone numbers, qualifications and hours of availability;
    • Contacting the appropriate interpreter on staff to interpret, if one is available and qualified to interpret; or
    • Obtaining an outside interpreter if a qualified interpreter on staff is not available.
    • The facility maintains a state directory (VDDHH) of qualified interpreters and translators.

Communicating by Telephone with Persons Who Are Deaf or Hard of Hearing

  • The Pavilion utilizes relay services for external telephone with TTY users. We accept and make calls through a relay service. The state relay service number is 1.800.828.1120.

For the following auxiliary aids and services, staff will contact the Executive Director who is responsible to provide the aids and services in a timely manner: 

  • Note takers, computer aided transcription services; telephone handset amplifiers; written copies of oral announcements; assistive listening devices; assistive listening systems; telephones compatible with hearing aids; closed caption decoders; open and closed captioning; telecommunications devices for deaf persons (TDDs); videotext displays; or other effective methods that help make aurally delivered materials available to individuals who are deaf or hard of hearing.

Some persons who are deaf or hard of hearing may prefer or request to use a family member or friend as an interpreter. However, family members or friends of the person will not be used as interpreters unless specifically requested by that individual and after an offer of an interpreter at no charge to the person has been made by the facility. Such an offer and the response will be documented in the patient’s medical record. If the patient chooses to use a family member or friend as an interpreter, issues of competency of interpretation, confidentiality, privacy and conflict of interest will be considered. If the family member or friend is not competent or appropriate for any of these reasons, competent interpreter services will be provided.

NOTE: Children and other patients will not be used to interpret, in order to ensure confidentiality of information and accurate communication.

For Persons Who are Blind or Who Have Low Vision

  • Staff will communicate information contained in written materials concerning treatment, benefits, services, waivers of rights, and consent to treatment forms by reading out loud and explaining these forms to persons who are blind or who have low vision.

For Persons with Speech Impairments

  • To ensure effective communications with persons with speech impairments, staff will contact the Executive Director who is responsible to provide the aids and services in a timely manner: writing materials, communications boards, and other communication aids.

For Persons with Manual Impairment

  • Staff will assist those who have difficulty in manipulating print materials by holding the materials and turning pages as needed, or by providing one or more of the following:
    • Note takers; computer aided transcription services; speaker phones, or other effective methods that help to ensure effective communication by individuals with manual impairments. For these and other auxiliary aids and services, staff will contact the Executive Director who is responsible to provide the aids and services in a timely manner.


The Pavilion and all of its programs and activities are accessible to and useable by disabled persons, including persons who are deaf, hard of hearing, or blind, or who have other sensory impairments. Access features include:

  • Convenient off street parking designated specifically for disabled persons;
  • Curb cuts and ramps between parking areas and building;
  • Level access into first floor level;
  • Fully accessible offices, meeting rooms, bathrooms, public waiting areas, and patient treatment areas.

© 2016 The Pavilion at Williamsburg Place. All Rights Reserved

The Pavilion at Williamsburg Place does not discriminate against any person on the basis of race, color,
national origin, disability, or age in admission, treatment , or participation in its programs, services and
activities, or in employment. For further information about this policy, contact: Patty Cranford, 757-941-6400,TDD 1-800-828-1120.

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