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. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO ME.

MY DUTIES

YOUR PROTECTED HEALTH INFORMATION (“PHI”) INCLUDES RECORDS THAT I CREATE AND OBTAIN WHEN I PROVIDE YOU CARE, SUCH AS A RECORD OF YOUR SYMPTOMS, EXAMINATION AND TEXT RESULTS, DIAGNOSES, TREATMENTS, AND REFERRALS FOR FURTHER CARE. IT ALSO INCLUDES PAYMENT INFORMATION THAT I MAINTAIN RELATED TO YOUR CARE. THE LAW REQUIRES ME TO KEEP YOUR PHI PRIVATE IN ACCORDANCE WITH THIS NOTICE OF PRIVACY PRACTICES (“NOTICE”), AS LONG AS THIS NOTICE REMAINS IN EFFECT. I AM ALSO REQUIRED TO PROVIDE YOU WITH A PAPER COPY OF THIS NOTICE, WHICH CONTAINS MY PRIVACY PRACTICES, MY LEGAL DUTIES, AND YOUR RIGHTS CONCERNING YOUR PHI.

FROM TIME TO TIME, I MAY REVISE MY PRIVACY PRACTICES AND THE TERMS OF MY NOTICE AS PERMITTED OF REQUIRED BY APPLICABLE LAW. SUCH REVISIONS TO MY PRIVACY PRACTICES AND MY NOTICES MAY BE RETROACTIVE. MY NOTICE WILL BE UPDATED AND MADE AVAILABLE TO MY PATIENTS PRIOR TO ANY SIGNIFICANT REVISIONS OF MY PRIVACY PRACTICES AND POLICIES.

PERMITTED USES AND DISCLOSURES

UNDER FEDERAL LAW, I MAY USED AND DISCLOSE YOUR PHI WITHOUT AUTHORIZATION FOR TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS. EXAMPLES OF SUCH POTENTIAL USES OR DISCLOSURES ARE PROVIDED BELOW:

• TREATMENT: YOUR PHI MAY BE USED BY OR DISCLOSED TO ANY PHYSICIANS OR OTHER HEALTH CARE PROVIDERS INVOLVED WITH THE MEDICAL SERVICES PROVIDED TO YOU.
• PAYMENT: YOUR PHI MAY BE USED OR DISCLOSED IN ORDER TO COLLECT PAYMENT FOR THE MEDICAL SERVICES PROVIDED TO YOU.
• HEALTH CARE OPERATIONS: YOUR PHI MAY BE USED OR DISCLOSED AS PART OF MY INTERNAL HEALTH CARE OPERATIONS. SUCH HEALTH CARE OPERATIONS MAY INCLUDE, AMONG OTHER THINGS, QUALITY OF CARE AUDITS OF MY AFFILIATES, CONDUCTING TRAINING PROGRAMS, ACCREDITATION, CERTIFICATION, LICENSING, OR CREDENTIALING ACTIVITIES.

OTHER USES AND DISCLOSURES WITHOUT AUTHORIZATION

WHILE THE FOLLOWING DISCLOSURES CAN BE MADE WITHOUT YOUR CONSENT OR AUTHORIZATION. WHENEVER FEASIBLE I WILL INFORM YOU PROMPTLY THAT I HAVE MADE SUCH A DISCLOSURE OR THAT I INTEND TO DO SO. I WILL EXERCISE MY PROFESSIONAL JUDGEMENT IN DECIDING WHETHER OR NOT TO MAKE SUCH A REPORT WITHIN THE REQUIREMENTS OF STATE, FEDERAL, OR LOCAL LAW, AND PROFESSIONAL ETHICS.

• ABUSE, NEGLECT, OR DOMESTIC VIOLENCE: AS REQUIRED BY LAW, I MAY DISCLOSE YOUR PHI TO REPORT SUSPECTED ABUSE, NEGLECT, OR DOMESTIC VIOLENCE.
• JUDICIAL AND ADMINISTRATIVE PROCEEDINGS: I MAY DISCLOSE YOUR PHI IN THE COURSE OF A JUDICIAL OR ADMINISTRATIVE PROCEEDING, IN ACCORDANCE WITH MY LEGAL OBLIGATIONS.
• MINORS: IF YOU ARE AN UN-EMANCIPATED MINOR UNDER MARYLAND LAW, THERE MAY BE CIRCUMSTANCES IN WHICH I DISCLOSE YOUR PHI TO A PARENT, GUARDIAN, 0R OTHER PERSON ACTING IN LOCO PARENTIS, IN ACCORDANCE WITH MY LEGAL AND ETHICAL RESPONSIBILITIES.
• NOTIFICATION: I MAY SUE OR DISCLOSE YOUR PHI TO NOTIFY A FAMILY MEMBER OR OTHER PERSON RESPONSIBLE FOR YOUR CARE ABOUT YOUR LOCATION, ABOUT YOUR GENERAL CONDITION, OR ABOUT YOUR DEATH. IF YOU ARE AVAILABLE, I WILL PROVIDE YOU AN OPPORTUNITY TO OBJECT BEFORE DISCLOSING ANY SUCH INFORMATION. IF YOU ARE UNAVAILABLE BECAUSE, FOR EXAMPLE, YOU ARE INCAPACITATED OR BECAUSE OF SOME OTHER EMERGENCY CIRCUMSTANCE. I WILL USE MY PROFESSIONAL JUDGEMENT TO DETERMINE WHAT IS IN YOUR BEST INTEREST AND WHETHER A DISCLOSURE MAY BE NECESSARY TO ENSURE AN ADEQUATE RESPONSE TO THE EMERGENCY CIRCUMSTANCES.
• PARENTS: IF YOU ARE A PARENT OF AN UN-EMANCIPATED MINOR, AND ARE ACTING AS THE MINOR’S PERSONA; REPRESENTATIVE. I MAY DISCLOSE HEALTH INFORMATION ABOUT YOUR CHILD TO YOU UNDER CERTAIN CIRCUMSTANCES. FOR EXAMPLE, I AM LEGALLY REQUIRED TO OBTAIN YOUR CONSENT AS YOUR CHILD’S PERSONAL REPRESENTATIVE IN ORDER FOR YOUR CHILD TO RECEIVE CARE FROMME. IN SOME CIRCUMSTANCES, I MAY NOT DISCLOSE HEALTH INFORMATION ABOUT AN UN-EMANCIPATED MINOR TO YOU. FOR EXAMPLE, IF YOUR CHILD IS LEGALLY AUTHORIZED TO CONSENT TO TREATMENT(WITHOUT SEPARATE CONSENT FROM YOU). CONSENTS TO SUCH TREATMENT, AND DOES NOT REQUEST THAT YOU BE TREATED AS HIS OR HER PERSONAL REPRESENTATIVE. I MAY NOT DISCLOSE YOUR CHILD’S PHI TO YOU WITHOUT YOUR CHILD’S WRITTEN AUTHORIZATION.
• PERSONAL REPRESENTATIVE: IF YOU ARE AN ADULT OR EMANIPATED MINOR, I AMY DISCLOSE YOUR PHI TO A PERSONAL REPRESENTATIVE AUTHORIZED TO ACT ON YOUR BEHALF IN MAKING DECISIONS ABOUT YOUR HEALTH CARE.
• PUBLIC SAFETY: CONSISTENT WITH MY LEGAL AND ETHICAL OBLIGATIONS, I MAY DISCLOSE YOUR PHI BASED ON A GOOD FAITH DETERMINATION THAT SUCH DISCLOSURE IS NECESSARY TO PREVENT A SERIOUS AND IMMINENT THREAT TO THE HEALTH OR SAFETY OF A PERSON OR THE PUBLIC.
• REQUIRED BY LAW: I MAY BE REQUIRED BY FEDERAL, STATE OR LOCAL LAW TO DISCLOSE YOUR PHI.

PATIENTS RIGHTS

YOU HAVE CERTAIN RIGHTS WITH RESPECT TO YOUR PHI.

• REQUESTING RESTRICTIONS: YOU MAY ASK ME TO LIMIT MY USE OR DISCLOSURE OF YOUR PHI. I AM NOT REQUIRED TO AGREE TO YOUR REQUEST, BUT IF I AGREE TO IT, I WILL ABIDE BY YOUR REQUEST EXCEPT AS REQUIRED BY LAW, IN EMERGENCIES, OR WHEN THE INFORMATION IS NECESSARY TO TREAT YOU. YOUR REQUEST MUST:

1. BE IN WRITING.
2. DESCRIBE THE INFORMATION THAT YOU WANT RESTRICTED.
3. STATE IF THE RESTRICTION IS LIMITED TO MY USE OR DISCLOSURE; AND
4. STATE TO WHOM THE RESTRICTION APPLIES.

• CONFIDENTIAL COMMUNICATIONS: YOU MAY ASK THAT I COMMUNICATE WITH YOU IN A PARTICULAR WAY, OR AT A CERTAIN LOCATION, TO MAINTAIN YOUR CONFIDENATIALITY. YOUR REQUEST MUST BE IN WRITING AND MUST TELL ME HOW YOU INTEND TO SATISFY YOUR FINANCIAL RESPONSIBILITY. YOU DO NOT HAVE TO GIVE A REASON FOR YOUR REQUEST.
• INSPECT AND COPY: YOU MAY REQUEST TO REVIEW, OR TO RECEIVE A COPY OF YOUR PHI THAT IS MAINTAINED IN MY FILES. IF I AM UNABLE TO SATISFY YOUR REQUEST, I WILL TELL YOU IN WRITING THE REASON FOR THE DENIAL AND YOUR RIGHT, IF ANY, TO REQUEST A REVIEW OF THE DECISION. I MAY CHARGE YOU A FEE FOR THIS SERVICE.
• AMENDMENT: YOU MAY ASK ME TO AMEND YOUR HEALTH INFORMATION IF YOU BELIEVE THAT IT IS INCORRECT OR INCOMPLETE. YOUR REQUEST MUST BE IN WRITING AND MUST INCLUDE A REASON TO SUPPORT THE AMENDMENT. YOUR REQUEST MAY BE DENIED IF I BELIEVE THAT THE INFORMATION IS COMPLETE AND ACCURATE, IF THE INFORMATION IS NOT PART OF THE MEDICAL INFORMATION THAT YOU WOULD BE PERMITTED TO INSPECT OR COPY, OR IF I DID NOT CREATE THE INFORMATION.
• ACCOUNTING OF DISCLOSURE: UNDER FEDERAL LAW, YOU MAY REQUST A LIST OF DISCLOSURES THAT I HAVE MADE OF YOUR MEDICAL INFORMATION OVER THE PREVIOUS SIX (6) YEARS. THIS RIGHT APPLIES TO DISCLOSURES OTHET THAN TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS AS DESCRIBED IN THIS NOTICE OF PRIVACY PRACTICES. YOUR FIRST REQUEST WITHIN A 12-MONTH PERIOD IS FREE, BUT I MAY CHARGE FOR ADDITIONAL LISTS WITHIN THE SAME 12-MONTH PERIOD.
• PAPER COPY OF THIS NOTICE: YOU ARE ENTITLED TO RECEIVE A PAPER COPY OF MY NOTICE OF PRIVACY PRACTICES BY USING THE CONTRACT INFORMATION SUPPLIED ON THE FIRST PAGE.
• FILE A COMPLAINT: IF YOU BELIEVE THAT I HAVE VIOLATE YOUR PRIVACY RIGHTS, YOU MAYT FILE A COMPLAINT DIRECTLY WITH ME USING THE CONTACT INFORMATION ON THE FIRST PAGE. YOU MAY ALSO FILE A COMPLAINT WITH THE SECRETARY OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES. YOU WILL NOT BE PENALIZED FOR COMPLAINING.
• PROVIDE AN AUTHORIZATION FOR OTHER USES AND DISCLOSURES: I WILL NOT DISCLOSE YOUR PHI FOR ANY REASON EXCEPT THOSE DESCRIBED IN THIS NOTICE, UNLESS YOU PROVIDE ME WITH A WRITTEN AUTHORIZATION TO DO SO. I MAY REQUEST SUCH AN AUTHORIZATION TO USE OR DISCLOSE YOUR PHI FOR ANY PURPOSE. BUT YOU ARE NOT REQUIRED TO GIVE ME SUCH AN AUTHORIATION AS A CONDITION OF YOUR TREATMENT. ANY WRITTEN AUTHORIZATION FROM YOU MAY BE REVOKED BY YOU IN WRITING AT ANY TIME, BUT SUCH REVOCATION WILL NOT AFFECT ANY PRIOR AUTHORIZED USES OR DISCLOSURES.