New Obstetrical Patient Information Form Page 11
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14J
A. G
, MD
UDITH
URDIAN
M
S
, MD
ICHELLE
PECTOR
P
E. S
, PA-C
ATRICIA
HEVOCK
M
T
-H
, CNM
ELANIE
HORNTON
UYCKE
HIPAA
N
P
P
OTICE OF
RIVACY
RACTICES
T
HIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN
. P
.
GET ACCESS TO THIS INFORMATION
LEASE REVIEW IT CAREFULLY
This Notice of Privacy Practices is not an authorization. However, it describes how we may use and disclose your protected health
information (PHI) to carry out 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. PHI 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 PHI that we may maintain at that time. Upon your request, we will provide you with any revised
Notice of Privacy Practices.
U
D
P
H
I
SES AND
ISCLOSURES OF
ROTECTED
EALTH
NFORMATION
Your PHI may be used and disclosed by your physician, our office staff and others outside of our office who are involved in your case
and treatment for the purpose of providing health care services to you. Your PHI may also be used and disclosed to pay your health
care bills and to support the operation of your physician’s practice. Following are examples of the types of uses and disclosures of
your PHI that your physician’s office is permitted to make. These examples are not meant to be exhaustive, but to describe the types
of uses and disclosures that may be made by our office.
T
REATMENT
We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the
coordination or management of your health care with another provider. For example, your PHI may be provided to other physicians
who may be treating you2. In addition, we may disclose your PHI from time-to-time to another physician or health care provider
(e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with
your healthcare diagnosis or treatment to your physician.
P
AYMENT
Your PHI will be used and disclosed, as needed, to obtain payment for your healthcare services provided by us or by another provider.
This may include certain activities that your health insurance plan may undertake before it approves or pays for the healthcare
services we recommend for you; including, making a determination or eligibility of coverage for insurance benefits, reviewing services
provided to you for medical necessity, undertaking utilization review activities, and obtaining approval for hospital admission.
H
C
O
EALTH
ARE
PERATIONS
We may use or disclose, as needed, your PHI in order to support the business activities or your physician’s practice. These activities
include, by are not limited to, quality assessment, employee review, training of medical students, licensing, fundraising, and
conducting or arranging for other business activities. We may also use a sign-in sheet at the registration desk where you will be
asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready
to see you. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment, and inform you about
treatment alternatives or other health-related benefits and services that may be of interest to you. If we use or disclose your PHI for
fundraising, we will provide you the choice to opt out of those activities. You many also choose to opt back in.
Other permitted and required uses and disclosures that may be made without your authorization or opportunity to agree or object
as required by law, include; communicable diseases, health oversight, abuse or neglect, food and drug administration requirements,
legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity, national
Healthcare for w om en, by w om en…
9711 Medical Center Drive, Suite 109, Rockville, MD 20850
|
301.762.5501
|
Fax 301.309.8727
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