Ninth Street Medical Center
310 West Ninth Street
Frederick, MD 21701
(301) 695-6800

Notice of Privacy Practices

 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

 

We are required to protect the privacy of health information about you and that can be identified with you, which we call “protected health information,” or “PHI” for short.  We must give you notice of our legal duties and privacy practices concerning PHI:

  • We must protect PHI that we have created or received about your past, present, or future health condition, health care we provide to you, or payment for your health care. 
  • We must notify you about how we protect PHI about you. 
  • We must explain how, when and why we use and/or disclose PHI about you. 
  • We may only use and/or disclose PHI as we have described in this Notice. 

 

This Notice describes the types of uses and disclosures that we may make and gives you some examples.  In addition, we may make other uses and disclosures, which occur as a byproduct of the permitted uses and disclosures described in this Notice.

 

We are required to follow the procedures in this Notice. We reserve the right to change the terms of this Notice and to make new notice provisions effective for all PHI that we maintain by first: Posting the revised notice in our offices, Making copies of the revised notice available upon request (either at our offices or through the contact person listed in this Notice)

 

WE MAY USE AND DISCLOSE PHI ABOUT YOU WITHOUT YOUR AUTHORIZATION IN THE FOLLOWING CIRCUMSTANCES.

  1.  We may use and disclose PHI about you to provide health care treatment to you.
  2.  We may use and disclose PHI about you to obtain payment for services.
  3. We may use and disclose your PHI for health care operations.
  4.  We may use and disclose PHI under other circumstances without your authorization. Those circumstances include:
When the use and/or disclosure is required by law.  
When the use and/or disclosure is necessary for public health activities.  
When the disclosure relates to victims of abuse, neglect or domestic violence.
When the use and/or disclosure is for health oversight activities.  
When the disclosure is for judicial and administrative proceedings
When the use and/or disclosure relates to decedents. 
When the use and/or disclosure relates to cadaver organ, eye or tissue donation purposes.
When the use and/or disclosure relates to medical research.  Under certain circumstances, we may disclose PHI about you for medical research.
When the use and/or disclosure is to avert a serious threat to health or safety
When the use and/or disclosure relates to specialized government functions.  
When the use and/or disclosure relates to correctional institutions and in other law enforcement custodial situations.  
We may contact you by telephone or mail to provide appointment reminders.
We may contact you by telephone or mail with information about treatment, services, products or health care providers.
 

You can object to certain uses and disclosures.

Unless you object, we may use or disclose PHI about you in the following circumstances:
  • We may share your name, your room number, and your condition in our patient listing with clergy and with people who ask for you by name.  We also may share your religious affiliation with clergy.
  • We may share with a family member, relative, friend or other person identified by you, PHI directly related to that person’s involvement in your care or payment for your care.  We may share with a family member, personal representative or other person responsible for your care, PHI necessary to notify such individuals of your location, general condition or death.  
  • We may share with a public or private agency (for example, American Red Cross) PHI about you for disaster relief purposes.  Even if you object, we may still share the PHI about you, if necessary for the emergency circumstances.
  • We may participate in one or more health information exchanges.  In general, health information exchanges facilitate the electronic exchange of health information across different organizations within a specified area, such as a health system, community, or broader region.  You may opt-out by filling out the opt-out form.
  • We may choose to participate in the Chesapeake Regional Information System for our patients (CRISP), a statewide internet-based health information exchange approved but not operated by a State of Maryland agency. You may opt-out by filling out the opt-out form or contacting CRISP at 1-877-952-7477.
 

** ANY OTHER USE OR DISCLOSURE OF PHI

ABOUT YOU REQUIRES YOUR WRITTEN AUTHORIZATION **

Under any circumstances other than those listed above, we will ask for your written authorization before we use or disclose PHI about you.  If you sign a written authorization allowing us to disclose PHI about you in a specific situation, you can later cancel your authorization in writing.   If you cancel your authorization in writing, we will not disclose PHI about you after we receive your cancellation, except for disclosures, which were being processed before we received your cancellation.

 

YOU HAVE SEVERAL RIGHTS REGARDING PHI ABOUT YOU.

1.     You have the right to request restrictions on uses and disclosures of PHI about you.

You have the right to request that we restrict the use and disclosure of PHI about you.  You may restrict disclosures to health plans concerning treatment for which you have paid for out-of-pocket.  We are not required to agree to your requested restrictions.  However, even if we agree to your request, in certain situations your restrictions may not be followed.  These situations include emergency treatment, disclosures to the Secretary of the Department of Health and Human Services, and uses and disclosures described in subsection 4 of the previous section of this Notice.  You may request a restriction by submitting your request in writing. 

2.     You have the right to request different ways to communicate with you.

You have the right to request how and where we contact you about PHI.  For example, you may request that we contact you at your work address or phone number or by email.  Your request must be in writing.  We must accommodate reasonable requests, but, when appropriate, may condition that accommodation on your providing us with information regarding how payment, if any, will be handled and your specification of an alternative address or other method of contact.  You may request alternative communications by submitting your request in writing to the Compliance and Privacy Officer.

3.     You have the right to view and copy PHI about you.

You have the right to request to view and receive a paper or electronic copy of PHI contained in clinical, billing and other records used to make decisions about you.  Your request must be in writing.  We may charge you related fees. Instead of providing you with a full copy of the PHI, we may give you a summary or explanation of the PHI about you, if you agree in advance to the form and cost of the summary or explanation. There are certain situations in which we are not required to comply with your request. Under these circumstances, we will respond to you in writing, stating why we will not grant your request and describing any rights you may have to request a review of our denial.  You may request to view and receive a copy of PHI by submitting your request in writing to the Compliance and Privacy Officer. You will be able to access decedent information of family members or others for 5 years from the date of death. 

4.     You have the right to request amendment of PHI about you.

You have the right to request that we make amendments to clinical, billing and other records used to make decisions about you.  Your request must be in writing and must explain your reason(s) for the amendment.  We may deny your request if: 1) the information was not created by us (unless you prove the creator of the information is no longer available to amend the record); 2) the information is not part of the records used to make decisions about you; 3) we believe the information is correct and complete; or 4) you would not have the right to view and copy the record as described in paragraph 3 above. We will tell you in writing the reasons for the denial and describe your rights to give us a written statement disagreeing with the denial. If we accept your request to amend the information, we will make reasonable efforts to inform others of the amendment, including persons you name who have received PHI about you and who need the amendment.  You may request an amendment of your PHI by submitting your request in writing to the Compliance and Privacy Officer.

5.     You have the right to a listing of disclosures we have made.

If you ask our contact person in writing, you have the right to receive a written list of certain of our disclosures of PHI about you.  You may ask for disclosures made up to six (6) years before your request (not including disclosures made prior to April 14, 2003).  We are required to provide a listing of all disclosures except the following:  For your treatment, for billing and collection of payment for your treatment, for our health care operations, made to or requested by you, or that you authorized, occurring as a byproduct of permitted uses and disclosures made to individuals involved in your care, for directory or notification purposes, or for other purposes previously described, allowed by law when the use and/or disclosure relates to certain specialized government functions or relates to correctional institutions and in other law enforcement custodial situations and as part of a limited set of information which does not contain certain information which would identify you. The list will include the date of the disclosure, the name (and address, if available) of the person or organization receiving the information, a brief description of the information disclosed, and the purpose of the disclosure.  If, under permitted circumstances, PHI about you has been disclosed for certain types of research projects, the list may include different types of information.   If you request a list of disclosures more than once in 12 months, we can charge you a reasonable fee.  You may request a listing of disclosures by submitting your request in writing to the Compliance and Privacy Officer.    

6.     You have the right to a copy of this Notice.

You have the right to request a paper or electronic copy of this notice at any time.  We will provide a copy of this Notice no later than the date you first receive service from us (except for emergency services, and then we will provide the Notice to you as soon as possible).

This notice is available on our web site www.fgamd.com.

YOU MAY FILE A COMPLAINT ABOUT OUR PRIVACY PRACTICES

If you think we have violated your privacy rights, or you want to complain to us about our privacy practices, you can contact the person listed below:

FREDERICK GASTROENTEROLOGY ASSOCIATES

Attention Linda Page-Rough
310 West Ninth Street
Frederick, MD 21701
(301) 695-6800 Fax (301) 695-6891

You may also send a written complaint to the United States Secretary of the Department of Health and Human Services.  If you file a complaint, we will not take any action against you or change our treatment of you in any way.