Privacy Policy

Effective Date of this Page: September 23, 2013
Updated: January 8, 2018
300 South Church Street
P.O. Box 20
Middletown, MD 21769
(301) 371-9000
(240) 566-7000 Fax
NOTICE OF PRIVACY PRACTICES
EFFECTIVE: September 23, 2013 UPDATED: January 8, 2018
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 or comments about this notice, or if you wish to request additional information about this notice, please contact the privacy officer, Heather Raithel, at:
300 South Church Street
Po Box 20
Middletown, MD 21769
hraithel@fmh.org
A. OUR COMMITMENT TO YOUR PRIVACY
Middletown Valley Family Medicine is dedicated to maintaining the privacy of your medical information. In conducting our business, we will create records regarding you and the treatment and services we provide to you. This notice applies to your medical information in the possession of the practice. We are required by law and out procedures:
 To maintain the confidentiality of your medical information;
 To provide you with this notice of our legal duties, commitment and privacy practices concerning your medical information: and
 To follow the terms of our notice of privacy practices, as it may be amended from time to time.
CHANGES TO THIS NOTICE
The terms of this notice apply to all records containing your medical information that are created or retained by us. We reserve the right to revise, change, or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of the information that we already have about you, as well as any of your medical information that we may receive, create, or maintain in the future. We will post a copy of our current notice in our offices in a prominent location, and you may request a copy of our most current notice during any visit.
WHO WILL FOLLOW THIS NOTICE
 Any practitioner or other person employed by or otherwise associated with the practice who is part of your care or otherwise has access to your medical information.
 All other employees of the practice.
B. HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION
The following categories describe, in general, the different ways in which we may use and disclose your medical information. Please note that each particular use or disclosure is not listed below. However, the different ways we are permitted to use and disclose your medical information do fall within one of the categories.
Treatment
The practice may use and disclose your medical information to treat you. For example, we may ask you to undergo laboratory tests and we may use the results to help us reach a diagnosis. Additionally, we may disclose your medical information to others who may assist in your care, such as a hospital and, if applicable, another practitioner, a spouse, children or parents.
Payment
The practice may use and disclose your medical information in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may share with your insurer details regarding your treatment to determine if your insurer will pay for your treatment. We also may use and disclose your medical information to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your medical information to bill you directly for services and items.
Health Care Options
The practice may use and disclose your medical information to operate our business. These uses and disclosures are important to ensure that you receive quality care. For example, the
Effective Date of this Page: September 23, 2013
Updated: January 8, 2018
practice may use medical information to evaluate the quality
of care you received from us, or to conduct management and
business planning activities for the practice.
Appointment Reminders
The practice may use and disclose your medical information to
remind you that you have an appointment.
Treatment Alternative/Health-Related Benefits and
Services
The practice may use and disclose your medical information to
inform you of treatment alternatives and/or health-related
benefits and services that may be of interest to you.
Required by Law
The practice will use or disclose medical information about
you when required by applicable law.
Public Health Activities
The practice may disclose your medical information for public
health activities including generally:
 To prevent or control disease, injury or disability;
 To maintain vital records, such as births and deaths;
 To report child abuse or neglect;
 To notify a person regarding potential exposure to a
communicable disease;
 To notify a person regarding a potential risk for
spreading or contracting a disease or condition;
 To report reactions to drugs or problems with
products or devices;
 To notify you if a product or device you may be
using has been recalled;
 To notify appropriate government agency(ies) and
authority(ies) regarding the potential abuse or neglect
of an adult patient (including domestic violence);
however, we will only disclose this information if the
patient agrees or we are required or authorized by law
to disclose this information; and
 To notify your employer under limited
circumstances, related primarily to workplace injury
or illness or medical surveillance.
Health Information Exchanges
We participate in one or more health information exchanges
involving health care providers who care for patients served
by Frederick County Providers. In general, health information
exchanges facilitate the electronic exchange of health
information across different organizations within a specified
area, such as a health system, a community, or a broader
region. If you have any questions regarding our participation
in these health information exchanges, please contact our
Privacy Officer for additional information.
We will share your information with this exchange as
permitted by law in order to facilitate the secure exchange of
your electronic health information between health care
providers and other health care entities for your treatment,
payment, or other permitted purposes (including health care
operations). If you do not want your information shared in this
way, you can opt out by completing a written opt out form,
which you can find at and submit to any of our offices. We
will comply with your opt out request to the extent required by
applicable law. Opting out will not preclude any participating
organization that already has received or accessed your
information from retaining such information. If you opt out,
you can choose to resume participation by submitting a written
request to one of our offices.
We have chosen to participate in the Chesapeake Regional
Information System for our Patients, Inc. (CRISP), a statewide
health information exchange. 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 all access to your
health information available through CRISP by calling 1-877-
952-7477 or completing and submitting an Opt-Put form to
CRISP by mail, fax or through their website at
www.crisphealth.org.
Abuse, Neglect, and Domestic Violence
If we make such a disclosure, we will inform you of it, unless
we think that informing you places you at risk of serious harm
or is otherwise not in your best interest.
Health Oversight Activities
The practice may disclose your medical information to a
health oversight agency for activities authorized by law.
Oversight activities include, for example, investigations,
inspections, audits, surveys, licensure and disciplinary actions;
civil, administrative, and criminal procedures or actions; or
other activities necessary for the government to monitor
government programs, compliance with civil rights laws, and
the health care system in general.
Lawsuits and Similar Proceedings
The practice may use and disclose your medical information in
response to a court or administrative order, if you are involved
in a lawsuit or similar proceeding. We also may disclose your
medical information in response to a discovery request,
subpoena, or other lawful process by another party involved in
the dispute, but only if we have made an effort to inform you
or your attorney of the request or to obtain an order protecting
the information the party has requested, if required by law.
Effective Date of this Page: September 23, 2013
Updated: January 8, 2018
Law Enforcement
The practice may release medical information if asked to do so
by law enforcement officials:
 Regarding a crime victim in certain situations, if we
are unable to obtain the person’s agreement;
 Concerning a death if such officials believe might
have resulted from criminal conduct;
 Regarding criminal conduct at our offices;
 In response to a warrant, summons, court order,
subpoena or similar legal process;
 To identify/locate a suspect, material witness,
fugitive or missing person; and
 In an emergency, to report a crime (including the
location or victim(s) of the crime, or the description,
identity or location of the perpetrator).
Coroners, Medical Examiners, and Funeral Directors
The practice may release medical information to a coroner or
medical examiner. This may be necessary, for example to
determine the cause of death. We may also release medical
information about patients to funeral directors as necessary to
carry out their duties.
Organ and Tissue Donation
The practice may use or disclose your medical information,
when appropriate, to organizations that handle organ and
tissue procurement, banking, or transplantation.
Serious Threats to Health or Safety
The practice may use and disclose your medical information
when necessary to reduce or prevent a serious threat to your
health and safety or the health and safety of another individual
or the public. Under these circumstances, we will only make
disclosures to a person or organization able to help prevent the
threat.
Specialized Government Functions
The practice may disclose your medical information if you are
a member of U.S or foreign military forces (including
veterans) and if required by the appropriate military command
authorities. In addition, we may disclose your medical
information to federal officials for intelligence and national
security activities authorized by law.
Furthermore, the practice may disclose your medical
information to correctional institutions or law enforcement
officials if you are an inmate or under the custody of a law
enforcement official. Disclosure for these purposes would be
necessary: (i) for the institution to provide health care services
to you, (ii) for the safety and security of the institution, and/or
(iii) to protect your health and safety or the health and safety
of other individuals.
Workers’ Compensation
The practice may release your medical information for
workers’ compensation and similar programs.
C. YOUR RIGHTS REGARDING YOUR
MEDICAL INFORMATION
You have the following rights regarding the medical
information that the practice maintains about you:
Requesting Restrictions
You have the right to request a restriction on our use or
disclose of your medical information for treatment, payment
or health care operations. Additionally, you have the right to
request that we limit our disclosure of your medical
information to individuals involved in your care or the
payment for your care, such as family members and friends.
We are not required to agree to your request, but we will if we
reasonably can. However, if we do agree with your request,
we are bound by our agreement except when otherwise
required by law, in emergencies, or when the information is
necessary to treat you. If we disclose your medical
information for emergency treatment, we will request that all
treating health care providers not further use or disclose the
information. In order to request a restriction, you must make
your request in writing to our Privacy Officer listed on page 1.
Your request must describe: (i) the information you wish
restricted; (ii) whether you are requesting to limit the
practice’s use, disclosure or both; and (iii) to whom you want
the limits to apply. Please see our receptionist to obtain an
appropriate request form.
Confidential Communications
You have the right to request that the practice communicates
with you about your health and related issues in a particular
manner, or at a certain location. For instance, you may ask that
we contact you by mail, rather than by telephone, or at home,
rather than work.
In order to request a confidential communication, you must
make a written request to our Privacy officer listed on page 1
specifying the requested method of contact, or the location
where you wish to be contacted. The practice will
accommodate reasonable requests. You do not need to give a
reason for your request but if your request is based on your
belief that if the request is not accepted you could be
endangered, you should tell us and we will accommodate the
request. Please see our receptionist to obtain an appropriate
request form.
Effective Date of this Page: September 23, 2013
Updated: January 8, 2018
Inspection and Copies
You have the right to inspect and obtain a copy of the medical
information that may be used to make decisions about you,
including your medical records and billing records, but not
any psychotherapy notes we have in our possession. You must
submit your request in writing to our Privacy Officer listed on
page 1 in order to inspect and/or obtain a copy of your medical
information. We may charge a fee for the costs of copying,
mailing, labor and supplies associated with your request. The
practice may deny your request to inspect and/or copy in
certain limited circumstances; however, you may request a
review of our denial. Reviews will be conducted not by the
person that denied your request, but by another licensed health
care professional chosen by us. Please see our receptionist to
obtain an appropriate request form.
Amendment
You may ask us to amen your medical information if you
believe it is incorrect or incomplete, and you may request an
amendment for as long as the information is kept or for the
practice. To request an amendment, your request must be
made in writing and submitted to our Privacy Officer listed on
page 1. You must provide us with a reason that supports your
request for amendment. We will deny your request if you fail
to submit your request (and the reason supporting your
request) in writing. Also, we may deny your request if you ask
us to amend information that is:
 Accurate and complete;
 Not part of the medical information kept by or for the
practice;
 Not part of the medical information which you would
be permitted to inspect and copy; or
 Not created by the practice, unless the individual or
entity that created the information is not available to
amend the information.
Please see our receptionist to obtain an appropriate request
form.
Accounting of Disclosures
You have the right to request an accounting of disclosures
which is a list of certain disclosures our organization has made
of your medical information. In order to obtain an accounting
of disclosures, you must submit your request to our Privacy
Officer listed on page 1. All requests for such an accounting of
disclosures must state a time period that may not be longer
than six years and may not include dates before April 14,
2003. The first list you request within a 12-month period is
free of charge, but the practice may charge you for additional
lists within the same 12-month period. We will notify you of
the costs involved with additional requests, and you may
withdraw your request in writing before you incur any costs.
Right to a Paper Copy of This Notice
You are entitled to receive a paper copy of the notice of
privacy practices at any time. To obtain a paper copy of this
notice, contact our Privacy Office listed on page 1.
Right to File a Complaint
If you believe your privacy rights have been violated, you may
file a complaint with the Practice and/or with the Secretary of
the Department of Health and Human Services. To file a
complaint with the practice, contact our Privacy Officer listed
on page 1. All complaints must be submitted in writing. Please
see our receptionist to obtain an appropriate request form. You
will not be penalized for filing a complaint.
Additional Rights
 You will be notified if a breach of unsecured
protected health information has occurred.
 You have the right to opt out of the fundraising
communication from the practice and the practice
cannot sell your health information without your
authorization.
 You have the right to request a copy of your
electronic medical record in electronic format.
 If you pay the practice out-of-pocket in full for your
treatment, then you can instruct the practice not to
share information about your treatment with your
health plan.
Right to Provide and Authorization for any Marketing and
Sale of your Medical Information or Other Uses and
Disclosures
The practice will obtain your written authorization for any
marketing and sale of your medical information and for uses
and disclosures of your medical information that are not
identified by this notice or are not permitted by applicable law.
Any information your provide us regarding the use and
disclosure of your medical information may be revoked by
you at any time in writing. After you revoke your
authorization, we will no longer use or disclose your medical
information for the reasons described in the authorization. Of
course, we are unable to take back any disclosures that we
have already made with your permission.
STATE LAW AND REGULATION
The federal law that protects the confidentiality of your
medical information is known by the acronym HIPAA.
HIPAA overrides state law when it provides more protection
of your medical information but is subordinate to state law and
regulation when state law provides more protection than that
provided by HIPAA. This notice is one required by HIPAA,
but the practice is also equally committed to maintain the
confidentiality of your medical information as required by
applicable state law and regulation.
Effective Date of this Page: September 23, 2013
Updated: January 8, 2018