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Notice
of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED AND HOW
YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
PURPOSE
OF THE NOTICE OF PRIVACY PRACTICES
This Notice of Privacy Practices is provided
to you as a requirement of the Health Insurance
Portability and Accountability Act of 1996
(HIPAA). HIPAA is about individual privacy,
and you should read this document carefully.
It describes how we may use and disclose your
protected health information for purposes
of treatment, payment or health care operations,
and for other purposes that are permitted
or required by law. It also describes your
rights to access and control your protected
health information. Protected health information
(PHI) is information about you, including
demographic information, that may identify
you and that relates to your past, present
or future physical condition and related health
care services, or payment for health care
services. A copy of this Notice of Privacy
Practices is also available as a PDF download:
Click
here to download (English)
Click
here to download (Spanish)
OUR
LEGAL DUTIES REGARDING PROTECTED HEALTH INFORMATION
We are required to follow the terms of this
Notice of Privacy Practices. We understand
that medical information about you and your
health is personal. We are committed to protecting
health information about you. In the course
of conducting our medical practice business,
we will create records regarding you and the
treatment and services we provide to you.
Your health record is the physical property
of the healthcare practitioner or facility
that compiled it, but the content is about
you and therefore belongs to you.
We
are required by law to:
- Ensure
protected health information that
identifies you is kept private;
- Give
you this notice of our legal duties
and privacy practices regarding your
protected health information; and
- Follow
the terms of the notice that is currently
in effect.
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REVISION
OF THE NOTICE OF PRIVACY PRACTICES
The terms of this notice apply to all records
containing your PHI that are created or retained
by our practice. We reserve the right to revise
or change the terms of this Notice of Privacy
Practices at any time. Any revision or amendment
to this notice will be effective for all of
your records that our practice has created or
maintained in the past, and for any of your
records that we may create or maintain in the
future. When the Notice of Privacy Practices
has been revised, our practice will post a copy
of the revised Notice in our offices in a visible
location. You may request a copy of our most
current Notice at any time.
HOW
WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH
INFORMATION
The following categories describe the different
ways in which we may use and disclose your
PHI without your authorization. For each category
of use or disclosure, an explanation follows
to explain what we mean and to present some
examples. Not every use or disclosure in a
category is listed.
Treatment: Our practice may use your
protected health information, including your
individually identifiable health information
(IIHI), to treat you. For example, we may
ask you to have laboratory tests (such as
blood or urine tests), and we may use the
results to help us reach a diagnosis. We might
use your PHI in order to write a prescription
for you, or we might disclose your PHI to
a pharmacy when we order a prescription for
you. Many of the people who work for our practice
- including, but not limited to, our doctors
and nurses - may use or disclose your PHI
in order to treat you or to assist others
in your treatment. Additionally, we may disclose
your PHI to others who may assist in your
care, such as your spouse, children or parents.
Finally, we may also disclose your PHI to
other healthcare providers for purposes related
to your treatment.
Payment: Our practice may use
and disclose your PHI in order to bill and
collect payment for the services and items
you may receive form us. For example, we may
contact your health insurer to certify that
you are eligible for benefits (and for what
range of benefits), and we may provide your
insurer with details regarding your treatment
to determine if your insurer will cover, or
pay for, your treatment. We also may use and
disclose your PHI to obtain payment from third
parties that may be responsible for such costs,
such as family members. Also, we may use your
PHI to bill you directly for services and
items. We may disclose your PHI to other healthcare
providers and entities to assist in their
billing and collection efforts.
Health Care Operations: Our
practice may use and disclose your PHI to
operate our business. As examples of the ways
in which we may use and disclose your information
for our operations, our practice may use your
PHI to evaluate the quality of care you received
from us, or to conduct cost-management and
business planning activities for our practice.
We may disclose your PHI to other health care
providers and entities to assist in their
health care operations. We may use or disclose
your protected health information, as necessary,
to provide you with information about treatment
alternatives or other health-related benefits
and services that may be of interest to you.
For example, your name and address will be
used to send you a newsletter about the services
we offer, health resources, and other information
related to your health.
Appointment Reminders: Our practice
may use and disclose your PHI to contact you
and remind you of an appointment. However,
it is our policy to get your written authorization
to leave messages.
Treatment Options: Our practice
may use and disclose your PHI to inform you
of potential treatment options or alternatives.
Health-Related Benefits and Services:
Our practice may use and disclose your PHI
to inform you of health-related benefits or
services that may be of interest to you.
Personal Representatives: A
person is your personal representative only
if they have authority by law to act on your
behalf in making decisions related to health
care. They then must be given the same consideration
as you and we may disclose your protected
health information to them. We may require
your personal representative to produce evidence
of his/her authority to act on your behalf.
We may not recognize him/her if we have a
reasonable belief that treating such person
as your personal representative could endanger
you and we decide that it is not in your best
interest to treat them as your personal representative.
In addition, in the event of your death, an
executor, administrator, or other person authorized
under the law to act on behalf of you or your
estate will be treated as your personal representative.
You may also be a personal representative
by law for another individual in your family,
such as a minor child or an incapacitated
adult. Minor children may have some rights
as specified in state consent laws that relate
directly to minors.
Individuals Involved in Your Care:
Unless you object, we may disclose to a member
of your family, a relative, a close friend,
or any other person you identify, your protected
health information that directly relates to
that person's involvement in your health care
or payment related to your health care. If
you are not present, we may disclose your
medical information based on our professional
judgment or whether the disclosure would be
in your best interest. In the same way, we
may also disclose your medical information
in the event of incapacity or in an emergency.
Business Associates: Some of
your health information may be subject to
disclosure through contract services to assist
this office in providing health care. For
example, it may be necessary to obtain specialized
assistance to process certain laboratory tests
or radiology images. To protect your health
information, we require these Business Associates
to follow the same standards held by this
office through terms detailed in a written
agreement.
OTHER
PERMITTED OR REQUIRED USES AND DISCLOSURES
THAT MAY BE MADE WITHOUT YOUR CONSENT, AUTHORIZATION,
OR OPPORTUNITY TO OBJECT
Our practice may also use and disclose your
protected health information in the following
situations without your authorization. These
situations include the following:
Disclosures
Required By Law:
Our practice will use and disclose your health
information when we are required to do so
by federal, state or local law.
Public Health Risks: Our practice
is required by law to disclose health information
to public health and/or legal authorities
charged with tracking reports of birth and
morbidity. This office is further required
by law to report communicable disease, injury
or disability.
Abuse and Neglect: We may disclose
your protected health information to a public
health authority that is authorized by law
to receive reports of abuse or neglect. In
addition, we may disclose your protected health
information to a governmental authority or
agency authorized to receive such information,
if we believe that you have been a victim
of abuse, neglect or domestic violence to
the governmental entity or agency authorized
to receive such information. In this case,
the disclosure will be made consistent with
the requirements of applicable federal and
state laws.
Health Oversight Activities:
Our practice may disclose your PHI to a health
oversight agency for activities authorized
by law. Oversight activities can include,
for example, investigations, inspections,
audits, surveys, licensure and disciplinary
actions; civil, administrative, and criminal
procedures or actions; or other activities
necessary for the government to monitor government
programs, compliance with civil rights laws
and the health care system in general.
Legal Proceedings: We may disclose
protected health information during any judicial
or administrative proceeding, in response
to an order of a court, or administrative
tribunal, if such disclosure is expressly
authorized by order. We may disclose protected
health information in response to a subpoena,
discovery request or other lawful process,
if the party seeking the information satisfactorily
assures us that reasonable efforts have been
made to either notify you of the request or
obtain a protective order.
Law
enforcement: We may disclose protected
health information for law enforcement purposes.
These law enforcement procedures include:
- Legal
orders, warrants, subpoenas, or summons;
- Information
for identifying and locating a suspect,
fugitive, material witness, or missing
person;
- Circumstances
pertaining to victims of a crime;
- Suspicion
that death occurred as a result of
criminal conduct
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Deceased
Patients:
Our practice may release PHI to a medical
examiner or coroner to identify a deceased
individual or to identify the cause of death.
If necessary, we also may release information
in order for funeral directors to perform
their job.
Organ Tissue Donation: Our practice
may release your PHI to organizations that
handle organ, eye or tissue procurement or
transplantation, including organ donation
banks, as necessary to facilitate organ or
tissue donation and transplantation if you
are an organ donor.
Research: Our practice may use
and disclose your PHI for research purposes
in certain limited circumstances. We will
obtain your written authorization to use your
PHI for research purposes except when
an Institutional Review Board or Privacy Board
has determined that the waiver of your authorization
satisfies the following: (i) the use or disclosure
involves no more than a minimal risk to your
privacy based on the following: (A) an adequate
plan to protect the identifiers from improper
use and disclosure; (B) an adequate plan to
destroy the identifiers at the earliest opportunity
consistent with the research (unless there
is a health or research justification for
retaining the identifiers or such retention
is otherwise required by law); and (C) adequate
written assurances that the PHI will not be
re-used or disclosed to any other person or
entity (except as required by law) for authorized
oversight of the research study, or for other
research for which the use or disclosure would
otherwise be permitted; (ii) the research
could not practicably be conducted without
the waiver; and (iii) the research could not
practicably be conducted without the access
to and use of the PHI.
Serious Threats to Health or Safety:
Our practice may use and disclose your PHI
when necessary to reduce or prevent a serious
threat to your health and safety or the health
and safety of another individual or the public.
Under these circumstances, we will only make
disclosures to person or organization able
to help prevent the threat.
Military: Our practice may use
and disclose your PHI if you are a member
of U.S. or foreign military forces (including
veterans) and if required by the appropriate
authorities.
National Security: Our practice
may use and disclose your PHI to federal officials
for intelligence and national security activities
authorized by law. We also may disclose your
PHI to federal officials in order to protect
the President, other officials or foreign
heads of state, or to conduct investigations.
Inmates: Our practice may use
and disclose your PHI to correctional institutions
or law enforcement officials if you are an
inmate or under the custody of a law enforcement
official. Disclosure for these purposes would
be necessary: (a) for the institution to provide
health care services to you, (b) for the safety
and security of the institution, and/or (c)
to protect your health and safety or the health
and safety of other individuals.
Workers' Compensation: Our practice
may use and disclose your PHI to comply with
laws relating to workers' compensation or
other similar programs established by law.
AUTHORIZATION
FOR OTHER USES AND DISCLOSURES
Uses and disclosures other than those in this
notice will be made only with your written
authorization. You may revoke an authorization
at any time in writing. If you revoke an authorization,
it will not affect any action taken or any
information released by us prior to receiving
and processing your request to revoke the
authorization. Please make these requests
in writing to our Privacy Official.
Forms may be requested through our office
at (301) 942-7600 or
Click
here to download form
YOUR
RIGHTS REGARDING YOUR PHI
Following is a statement of your rights with
respect to your protected health information
and a brief description of how you may exercise
these rights.
Right to Confidential Communications:
You have the right to request that our practice
communicate with you about your health and
related issues in a particular manner or at
a certain location. For instance, you may
ask that we contact you at home, rather than
at work. In order to request a type of confidential
communication, you must make a written request
to our Privacy Official specifying
the requested method of contact, or the location
where you wish to be contacted. Our practice
will accommodate reasonable requests. You
do not need to give a reason for your request.
Forms may be requested through our office
at (301) 942-7600 or
Click
here to download form
Right to Request Restrictions:
You have the right to request a restriction
in our use or disclosure of your PHI for treatment,
payment or health care operations. Additionally,
you have the right to request that we restrict
our disclosure of your PHI to only certain
individuals involved in your care or the payment
for your care, such as family members and
friends. We are not required to agree
with your request; however, if we do agree,
we are bound by our agreement except when
otherwise required by law, emergencies, or
when the information is necessary to treat
you. In order to request a restriction in
our use or disclosure of your PHI, you must
make your request in writing to our Privacy
Official. Your request must describe in
a clear and concise fashion:
| (a) |
the
information you wish restricted; |
| (b) |
(whether
you are requesting to limit our practice's
use, disclosure or both; |
| (c) |
and
to whom you want the restrictions to apply. |
You
may revoke a restriction at any time in writing.
We may also terminate our agreement to restriction
and would contact you if this situation should
occur. Forms
may be requested through our office at (301)
942-7600 or Click
here to download form
Right
of Access to Inspect and Copy: You
have the right to inspect and obtain a copy
of the PHI that may be used to make decisions
about you, including patient medical records
and billing records. You may not inspect or
copy the following records: psychotherapy
notes; information compiled in reasonable
anticipation of, or use in, a civil, criminal,
or administrative action or proceeding, and
protected health information that is subject
to law that prohibits access to protected
health information. You must submit your request
in writing to the Medical Records Department,
in order to inspect and/or obtain a copy of
your PHI. Our practice may charge a fee for
the costs of copying, mailing, labor and supplies
associated with your request. In most cases,
we will provide the requested information
within 30 days if the information is maintained
on site or within 60 days if the information
is maintained offsite. When a decision to
deny access has been made, you may have the
right to have this decision reviewed in some
circumstances. Please make this request in
writing to our Privacy Official. Forms
may be requested through our office at (301)
942-7600 or Click
here to download form
Right to Amend: You may ask
to amend your health information if you believe
it is incorrect or incomplete, and you may
request an amendment for as long as the information
is kept by or for our practice. To request
an amendment, your request must be made in
writing and submitted to our Privacy Official.
You must provide us with a reason that supports
your request for amendment. Our practice will
deny your request if you fail to submit your
request (and the reason supporting your request)
in writing. Also, we may deny your request
if you ask us to amend information that is
in our opinion; (a) accurate and complete;
(b) not part of the PHI kept by or for the
practice; (c) not part of the PHI which you
would be permitted to inspect and copy; or
(d) not created by our practice, unless the
individual or entity that created the information
is not available to amend the information.
In most cases, we will act upon your request
within 60 days. If we deny your request to
amend, you have the right to file a statement
of disagreement with us and we may prepare
a rebuttal to your statement and will provide
you with a copy of any such rebuttal. Please
make this request in writing to our Privacy
Official. Forms may be requested through
our office at (301) 942-7600 or
Click
here to download form
Right to Receive an Accounting of Disclosures:
You may request in writing to obtain an accounting
of disclosures. This right applies to disclosures
we have made for purposes not related to treatment,
payment or healthcare operations as described
in this Notice of Privacy Practices. It excludes
disclosures we may have made to you, to family
members or friends involved in your care,
to a personal representative, or to disclosures
you have specifically authorized. You have
the right to receive an accounting of disclosures
that occur after April 14, 2003, and for a
specific period of time up to six years. You
may also request a shorter specific time frame.
The first list you request within a 12-month
period is free of charge, but our practice
may charge you for additional lists within
the same 12-month period. Our practice will
notify you of the costs involved with any
additional requests, and you may choose to
withdraw your request before you incur any
costs. Please make your request in writing
to our Privacy Official.
Click
here to download form
Right to a Paper Copy of This Notice:
You are entitled to receive a paper copy of
our notice of privacy practices. You may ask
us to give you a copy of this notice at any
time. To obtain a paper copy of this notice,
contact our office at (301) 942-7600, or view
and print a copy electronically by Clicking
here to download the notice.
Right to File a Complaint: If
you believe your privacy rights have been
violated, you may file a complaint with our
practice or with the Secretary of the Department
of Health and Human Services. To file a complaint
with our practice, contact our Privacy
Official. All complaints must be submitted
in writing. You will not be penalized for
filing a complaint.
Click
here to download form
YOU MAY SEND YOUR WRITTEN REQUESTS AND
QUESTIONS TO OUR PRIVACY OFFICIAL:
Margaret M. Dieckhoner
2730 University Boulevard West, Suite #310
Wheaton, MD 20902
(301) 942-7600
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