Notice of Privacy Practice

Chesapeake Urology Associates, P.A.

Notice of Privacy Practice

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.

We have chosen to participate in the Chesapeake Regional Information System for our Patients (CRISP), a regional health information exchange serving Maryland and D.C. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. You may “opt-out” and disable access to your health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax or through their website at www.crisphealth.org. Public health reporting and Controlled Dangerous Substances information, as part of the Maryland Prescription Drug Monitoring Program (PDMP), will still be available to providers.

Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have a right to adequate notice of the uses and disclosures of your protected health information (PHI) (i.e., information that discloses your identity or leads to disclosure of your identity) that may be made by this medical practice. You are also entitled to notice of your rights and the duties of this practice with respect to your personal health information.

We respect your right to privacy and understand that your medical information is personal to you. In order to provide medical services to you, we create paper and electronic records about your health and the care we provide. Your personal health information is confidential and this notice is intended to help you understand how our practice uses and discloses your personal health information and what rights you have with respect to your medical information.

Our practice has the following duties with respect to your personal health information:

1. We are required by law to maintain the privacy of your personal health information.
2. We must provide you with notice of our legal duties and privacy practices with respect to personal health information.
3. We must abide by the terms of the notice of privacy practices that is currently in effect.

How We May Use and Disclose Your Information

The following describes how our practice is permitted by law to share your personal health information with others in order to provide you with medical care. This notice does not describe every use or disclosure our practice makes; it is intended as a general overview.

Medical Treatment. We may need to share information about you in order to provide medical care to you. For example, we may share information with other physicians, nurses or healthcare professionals entering information into your medical records relating to your medical care and treatment. We may share information about you including x-rays, prescriptions and requests for lab work.

Payment. We may need to disclose information about the treatment, procedures or care our practice provided to you in order to bill and receive payment for the services we provided. We may share this information with you, an insurance company or any third party responsible for payment. We may also need to disclose personal health information about you with your health plan and/or referring physician in order to obtain prior authorization for treatment, to determine whether payment for the treatment is covered by your plan or to facilitate payment of a referring physician.

Healthcare Operations. In order to help us run our practice more efficiently and provide better patient care, health information may incidentally be available such as on sign-in sheets or business associates that may be given access to our computer systems containing your information and provide a service for our medical practice. An example is our software vendors who provide assistance with data and records management or claims payment on our behalf.

Required by Law. We will disclose medical information related to you if required to do so by state, federal or local law.

Public Health Activities/Risks. Your medical information may be disclosed to a public health authority that is authorized by law to collect or receive such information for public health activities.

Certain disclosures may be made for public health activities in the following circumstances:

1. To prevent or control disease, injury or disability
2. To report of births or deaths
3. To report child abuse or neglect
4. To report reactions to medications or product defects
5. To notify individuals of product recalls
6. To notify a person who may have been exposed to a communicable disease or at risk of contracting or spreading a disease or condition
7. If our practice reasonably believes a person is the victim of abuse, neglect, or domestic violence, we may disclose personal health information to the appropriate authority. We will only make this disclosure if you agree to the disclosure or we are required or authorized to do so by law without your permission.

Appointment Reminders or Treatment Alternatives. Our practice may use and disclose medical information about you to provide you with reminders that you are due for care or you have an upcoming appointment. We may also wish to provide you with information on treatment alternatives or other health-related benefits that may be of interest to you. We may contact you by phone, fax or e-mail. We will make every effort to protect your privacy when leaving a message for you and try to reveal as little confidential information as possible (e.g., when leaving a message on your answering machine that may be heard by others).

Research and teaching. Under certain circumstances, our practice may use or disclose your personal health information for research or teaching purposes. Our practice cannot use or disclose information about you without your written authorization, but we may if the authorization requirement has been waived by a Review Board who has assessed the effect of the research protocol on your privacy rights and interests and certified that there are adequate controls in place to protect your information from improper use and disclosure or has been approved by the curriculum committee of the educational institution. Our practice may also disclose information about you in preparing to conduct research (e.g., to help them find patients who may be qualified to participate in a particular study), but your information will not leave our practice. We will make all attempts to make your information non-identifiable, but we may not always be able to guarantee this. If however, the researcher will have access to information that will identify you, we will seek to obtain your permission (though we cannot guarantee this). We will always obtain your specific authorization if required by law.

To Avert Serious Threat to Health or Safety. If our practice believes, in good faith, that a use or disclosure of your medical information is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public, we may disclose your medical information.

Worker’s Compensation. We may release medical information about you for work-related illness or injury for workers? compensation or other related programs.

Health Oversight Activities. Your personal health information may be disclosed to federal, state or local authorities as part of an investigation or government activity authorized by law. This may include audits, civil, administrative or criminal investigations, inspections, licensure or disciplinary actions or other activities necessary for the oversight of the health care system, government benefit programs and compliance with government regulatory programs or civil rights laws.

Law Enforcement. We may disclose your personal health information to law enforcement individuals if we are required to do so by law. We may also disclose medical information about you in compliance with a court order, warrant or subpoena or summons issued by the court. We will make best efforts to contact you about these types of requests so that you can obtain an order restricting or prohibiting disclosure of the information requested. We may also use such information to defend ourselves in actions or threatened actions that may be brought against our practice.

Coroners, Medical Examiners and Funeral Directors. We may release personal health information to a coroner or medical examiner for the purposes of identification, determining a cause of death or other duties as authorized by law. We may also release medical information to funeral directors as necessary to carry out their duties with respect to the deceased.

Organ, Eye, Tissue Donation. If you are an organ donor, we may disclose your personal health information to organ procurement organizations, or other entities that facilitate tissue donation or transplantation.

Inmates. If you become an inmate of a correctional institution or within the custody of law enforcement officials, we may disclose medical information about you to allow the institution to provide you with medical care, to protect the health and safety of yourself and others, or for the safety and security of the correctional institution.

Other uses and disclosures will be made only with your written authorization and you may revoke your authorization at any time.

Patient Rights

You have the following rights with respect to your personal health information:

Right to Receive Personal Health Information Confidentially. You have the right to receive confidential communications of your personal health information by alternate means or at alternate locations. For example, if you would like for us only to communicate with you at home, and never at your workplace or to send information to you on your workplace e-mail, you may request this of our practice. You must make this request in writing but do not need to disclose the reason for your request. We will attempt to accommodate all reasonable requests. Please be specific as to how or where you wish us to communicate with you.

Right to Inspect and Copy. You have the right to inspect and copy your medical record that has been created to treat you and is used to make decisions about your care. This includes medical and billing records. Records related to your care may also be disclosed to an authorized person such as a parent or guardian upon proper proof of a legitimate legal relationship. You must submit your request in writing to inspect and copy your records. If you would like to copy your records, our practice may charge you fees for the cost of copying records, mail or other minimal costs associated with your request. Please see a staff person for the required form to be completed.

Right to Amend. If you think there is information in your record that may be inaccurate or incomplete, you have the right to request an amendment or clarification of information in your record.
Your request to make an amendment to your record must include the following and may be refused if the following elements are not met:

1. Submit your request in writing
2. Describe what you would like the amendment to say and your reasoning for why the change should be made
3. The amendment must be dated, signed by you and notarized

Please note that we will not change information created by third parties, if the information is not part of the medical information kept by our practice or we believe the information you provided to us is inaccurate or incomplete. We reserve the right to deny your request if we have reason to believe the information is accurate. Your request will be made part of your medical record. Please see a staff person for the required form to be completed.

Right to Restrict Uses and Disclosures. You have the right to request restrictions on how our practice makes certain uses and disclosures of your personal health information for treatment, payment or healthcare operations. You may restrict how much information we may provide to family members regarding your treatment or payment for your care. You also have the right to pay in full for your healthcare services and request that we not disclose your medical information to a health plan or other entity. You may also restrict certain types of marketing materials related to your care or treatment.

We are not required to agree to your request or we may not be able to comply with your request, but we will do all that we can to accommodate your request. If we agree to your request, we will comply.

Maryland Law states if the information is required to provide emergency treatment to you, or under our prerogative to grant access to a minor child’s health information by parents, we may comply, but need not, except in the case of an abortion where we will not. {Health General Articles 20-102 (f)}

Your request must be in writing and include the following:

1. What information you would like to limit
2. Whether you want to limit our use, or disclosure or both
3. To whom you want the limits to apply (e.g., disclosures to parents, children, spouse, etc.)

Please see a staff person for the correct form to complete.

Right to Copy of Notice. You have the right to obtain a copy of our notice of privacy practices upon request at any time. Please see our notice in the waiting room or ask for a copy at the reception desk.

Information Breach Notification. Chesapeake Urology Associates as an entity understands that we are obligated to inform patients of any breach of health care information. A breach involving 500 people or less, requires written notification to each affected individual. This notice must contain the details of the breach, the information disclosed, and the steps being taken by the practice to avoid any future breaches, as well as explaining the rights of the patient(s) in protecting their private healthcare information. If the breach involves more than 500 persons, Chesapeake Urology Associates is obligated to notify the Department of Health and Human Services as well as the local media outlets.

Changes to this Notice. Our practice is required to abide by the terms of this notice, which will go into effect no later than April 14, 2003. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all personal health information we already have about you and may obtain in the future. If we change our notice, we will post notice of this change thirty (30) days prior to making the change effective. All revised notices will be posted and made available to you in our waiting room promptly.

Practice Contact. If you would like more information about this notice, please contact our office at 410-581-1600. If you have any complaints regarding our privacy practices, please address your complaint to them in writing and follow the designated complaint process below.

Complaints. If you believe your privacy rights may have been violated or you become aware of a privacy concern you would like to report to our practice, please follow this complaint process:

Send a written letter to Chesapeake Urology Associates Compliance Officer Attn: Privacy, 25 Crossroads Drive, Suite 306, Owings Mills, MD 21117 and include the following information:

1. Name and Address
2. Social Security Number or Patient Identification Number
3. Detailed description of the circumstances surrounding your complaint including dates, times and any relevant information to help us understand your complaint.
4. Contact information
5. Signature and Date
6. Please allow 30 days for an answer from our practice regarding your complaint.
7. If you are not satisfied with our response to your complaint, you may notify the Secretary of the Department of Health and Human Services.

Please note, all concerns or complaints regarding your personal health information are important to our practice. There will be no retaliation against you for filing a complaint with our office. However, our staff and providers may face sanctions up to and including termination for failing to abide by these policies.

Electronic Notice. This privacy notice is posted on our web site.

Date of Last Revision: March 27, 2018

Effective Date. April 2003