Notice of Privacy Practices
West Ocean City Injury & Illness Center
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. If you have any questions about this Notice, please contact our Privacy Officer: Cynthia Randolph.
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and other purposes that are permitted or required by the law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices.
Uses and Disclosures of Protected Health Information
You will be asked by our facility to sign a consent form upon registration.
Your Protected Health Information may be used or disclosed by:
Ÿ Our Facility
Ÿ Our Healthcare Provider
Ÿ Our front and back office staff
Ÿ Others outside of our office for the purpose of providing healthcare services to you.
Please be advised that we may also call you by name in the waiting room when your provider is ready to see you.
Your protected Health Information may be used or disclosed for:
Ÿ Medical treatment or services
Ÿ To other providers who may be treating you (when we obtain authorization from you)
Ÿ To providers to whom you have been referred to ensure that he/she has necessary information to diagnose treat
Ÿ To obtain payment and receive reimbursement from your healthcare plan or guarantor
Ÿ For preauthorization/prior approval for services/treatment rendered or to be rendered
Ÿ Any other healthcare operations that are necessary for the day to day activities of this facility
Other Uses and Disclosures of Protected Health Information:
Ÿ Will be based upon your written authorization unless otherwise permitted or required by law
Ÿ May be done without your presence/consent/objection if the healthcare provider, using professional judgment, determine whether the disclosure is in your best interest (in this case only protected health information that is relevant to your healthcare will be disclosed)
Ÿ Will be made to family members, close friends, any other person you identify below as it directly relates to their involvement in your healthcare
Name:__________________________________ Relation:_______________________ Phone:________________
Ÿ To an authorized public or private entity to assist in disaster relief efforts
Ÿ For emergency treatment a.) attempt will be made to obtain your consent as soon as reasonably practical after delivery of treatment b.) if your provider is required by law to treat you and the provider has attempted to obtain your consent but is unable to obtain it, he or she may still use or disclose your PHI to treat you
Ÿ As to the extent that the law requires
Ÿ Public health authorities as by permitted by law to collect or receive the information for purpose of controlling disease, injury or disability
Ÿ Communicable diseases if authorized by law, to a person who may have been exposed or be at risk of contracting or spreading disease/condition
Ÿ Any health oversight agency, as authorized by law, for audits, investigations, and infections
Ÿ To a public health authority that is authorized by law, to receive reports of child abuse or neglect
Ÿ To public health authority if the provider believes that you have been a victim of abuse, neglect, or domestic violence as required by applicable federal and state laws
Food and Drug Administration:
Ÿ to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
Legal Proceedings:
Ÿ in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal, in certain conditions in response to a subpoena, discovery request or other lawful process.
Law Enforcement:
Ÿ as applicable legal requirements are met (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premise of the practice, (6) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.
Coroners:
Ÿ for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law.
Ÿ for cadaver organ, eye, or tissue donation purposes.
Criminal Activity:
Ÿ consistent with applicable federal and state laws, if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
Ÿ to identify or apprehend an individual.
Workers’ Compensation:
Ÿ as authorized to comply with worker’s compensation laws and other similar legally established programs.
Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164,500 et, seq.
Your Rights:
Right to inspect and copy your protected health information:
Ÿ information about you that is contained in a designated record set
Ÿ Medical and any other records that your provider and the practice use for making decisions about you. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information complied in reasonable anticipation of, or use in a civil, criminal, or administrative action or proceeding and PHI that is subject to law that prohibits access to PHI.
Right to restrict disclosure of your PHI:
Right to amend your PHI in a designated record set:
Right to receive an accounting of certain disclosures we have made, if any, of your protected health information:
a) Date of disclosure c) What PHI was disclosed
b) Who received PHI d.) For what purpose
You have the right to obtain a paper copy of this notice from us: upon request, even if you have agreed to accept this notice electronically.
Right to request PHI via “alternate means” or at “alternate locations”:
Please sign below indicating that you have read and understand the above.
Signature: _____________________________ Date: ____________________
12547 Ocean Gateway Ocean City, MD 21842-9689 Phone: (410) 213-0119 Fax: (410) 213-2875
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