PRIVACY NOTICE OF STEPHANIE DURRUTHY, M.D., P.A.
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.
THIS NOTICE GIVES YOU INFORMATION REQUIRED BY LAW about the duties and privacy practices of STEPHANIE DURRUTHY, M.D., P.A. (the "PA") to protect the privacy of your individually identifiable health information or ?Protected Health Information,? as that term is defined under the Health Insurance Portability and Accountability Act of 1996 ("Information"), in providing for your medical treatment and needs. ?You? or ?Your? will mean the individual on whom the Information is kept. If you are an unemancipated minor and Maryland state law gives your parent, guardian or other person, acting as your parent (?in loco parentis?) authority to act on your behalf, that person will be requested to acknowledge receipt of this Notice and exercise the rights contained herein on your behalf.
THE EFFECTIVE DATE OF THIS NOTICE IS APRIL 14, 2003. The PA is required to follow the terms of this Notice until it is replaced. The PA may make changes to the terms of this Notice at any time. Upon your request, the PA will provide you with a copy of its current Notice. The PA reserves the right to make the new changes apply to Information maintained by the PA before and after the effective date of the new Notice.
Purposes for which the PA May Use or Disclose Your Medical Information With Your Consent The PA may request your consent for the use and disclosure of your Information for treatment, payment or health care operations as described below:
· Treatment Purposes. For example, certain Information, excluding notes of your counseling session recorded by the PA or another mental health professional (?Psychotherapy Notes?) and kept separate from your medical record, may be disclosed to other health care professionals or providers in planning for your care and treatment.
· Payment. For example, your Information may be used and disclosed to submit claims to your insurer and/or to obtain payment for services provided.
· Health Care Operations. For example, your Information may be used and disclosed by the PA to engage in case management, coordination of your care and schedule your appointments.
· Health Care Services. Your Information may be used and disclosed to contact you and to give you information about treatment alternatives or other health benefits and services that may be of interest to you.
Uses and Disclosures With Your Verbal Consent Unless you object, your Information may be used for the PA? directory and may be disclosed to a family member, friend or other person designated by you or as designated by the law.
Uses and Disclosures with Your Authorization Except as provided below, your Information will not be used for non-routine purposes unless you give the PA your written authorization to do so. The PA will request your authorization to use and disclose Psychotherapy Notes relating to your treatment, except for Psychotherapy Notes: (i) used internally by the PA; (ii) used by the PA to defend itself in a legal action or proceeding brought by you; (iii) used by the originator of the Notes, or (iv) required to be disclosed by law. If you give the PA written authorization to use or disclose your Information with certain exceptions, you may revoke it in writing at any time. Your revocation will be effective for the Information the PA maintains, unless the PA has taken action in reliance of your authorization.
Uses And Disclosures Without Your Consent or Authorization · As required by law. The PA must provide your Information to the U.S. Department of Health and Human Services and to you, upon request, with certain exceptions.
· To Business Associates. Your Information may be disclosed to the PA's business associates who require the Information to perform a function for the PA (i.e. accountant). Each business associate of the PA must agree in writing to ensure the continuing confidentiality and security of your Information.
Additionally, your Information may be used and disclosed without your consent, opportunity to agree or disagree or authorization for other reasons including:
· To comply with legal proceedings, such as a court or administrative order or subpoena;
· To law enforcement officials for limited law enforcement purposes;
· For research purposes in limited circumstances;
· To a coroner, medical examiner, or funeral director about a deceased person;
· To an organ procurement organization in limited circumstances;
· To avert a serious threat to your health or safety or the health or safety of others;
· To a governmental agency authorized to oversee the health care system or government programs;
· To federal officials for lawful intelligence, counterintelligence and other national security purposes;
· To public health authorities for public health purposes; and
· To appropriate military authorities, if you are a member of the armed forces.
Your Rights You may make a written request to the PA to do one or more of the following concerning your Information:
· To put additional restrictions on the use and disclosure of your Information.
· To communicate with you in confidence about your Information by a different means or at a different location than the PA is currently doing.
· To see and get copies of your Information, with certain exceptions which may include denying you access to Psychotherapy Notes.
· To correct your Information.
· To receive a list of disclosures of your Information that the PA, and its business associates, make for certain purposes for six (6) years prior to your request (after April 14, 2003), with certain exceptions permitted by law, including exceptions for disclosures made to you or made pursuant to your authorization.
· To send you a paper copy of this Notice if you receive this Notice by e-mail or on the internet.
If you want to exercise any of these rights described or require further information about the PA's privacy practices, please contact the PA? Privacy Officer at the address below. Please know that in certain instances, the PA does not have to agree to your request. The PA will give you the necessary information and forms for you to complete and return. The PA may charge you a fee of ¢.59 per page for copying.
Complaints If you believe your privacy rights have been violated by the PA, you have the right to complain to the PA or to the Secretary of the U.S. Department of Health and Human Services. You may file a written complaint with the PA by contacting the Privacy Officer at the address below. There will be no retaliation against you if you choose to file a complaint with the PA or with the U.S. Department of Health and Human Services.
Contact Office To request additional copies of this Notice or to receive more information about the PA's privacy practices or your rights, please contact the Privacy Officer at:
Stephanie Durruthy, M.D., P.A. Dorsey Hall Professional Park 5074 Dorsey Hall Drive, Suite 105 Ellicott City, Maryland 21042
Telephone: (410) 992-0272 Fax: (410) 964-0048