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. PLEASE REVIEW IT CAREFULLY.
Effective Date: April 14, 2003 Revised: October 2011, Revised: September 2013

WHO WILL FOLLOW THIS NOTICE
This notice describes our Health System’s privacy practices and those of:

• All of its subsidiaries including Anne Arundel Medical Center, Anne Arundel Diagnostics Imaging, Pathways Alcohol and Drug Treatment Center, Health Care Enterprises, Physician Enterprise LLC, Anne Arundel Heath System Research Institute, and the Foundation.
• All healthcare professionals authorized to enter information into your medical record.
• All departments and units of the Health System, diagnostic and treatment centers.
• All medical staff and contracted hospital-based physicians and their billing agents.
• Any member of the volunteer group we allow to help you while you are in the Health System.
• All categories of employees including temporary and contractual staff. All Business Associates.

All these persons, entities, sites, and locations follow the terms of this notice. In addition, these persons, entities, sites, and locations may share medical information with each other for treatment, payment, or Health System operations purposes as described in this notice.

OUR PLEDGE REGARDING MEDICAL INFORMATION
We understand that medical information about you and your health is personal. We are committed to protecting your medical information. We create a record of the care and services you receive at the Health System. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the Health System, whether made by Health System personnel, your personal doctor or our contracted Medical Center based physicians. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office or clinic.  This notice will tell you about the ways in which we may use and disclose your medical information. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

• Make sure that medical information that identifies you is kept private.
• Give you this notice of our legal duties and privacy practices with respect to medical information about you.
• Follow the terms of the notice that is currently in effect.
• In the event your health information is breached, we are required to provide you with notice of the breach.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of these categories.

For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other Health System personnel who are involved in your care. For example, a doctor treating you for a broken hip may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. We also may disclose medical information about you to people outside the Health System who may be involved in your ongoing care, such as family members, clergy, or others who provide services that are part of your care, such as therapists or physicians. AAHS participates in the Chesapeake Regional Information System for our Patients (CRISP), a statewide health information exchange (HIE). Basic identifying and clinical information regarding your visits to the medical center may be shared with the HIE for the purpose of diagnosis and treatment as permitted by law. Other providers participating in CRISP may access this information as part of your treatment. You may “opt-out” and prevent searching of your 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.

For Payment. We may use and disclose medical information about you to bill and collect payment from you, your insurance company or a third party payer for the services you received. For example, we may need to give your health plan information about treatment you received at the Health System so your health plan will pay us or reimburse you for the treatment. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. Our facilities may share your information with other providers who are involved in your care for their payment purposes.

For Healthcare Operations. We may use and disclose medical information about you for day-to-day operations. These uses and disclosures are necessary to run the Medical Center, diagnostic and treatment centers and make sure that all of our patients receive quality care. For example, we may use your medical information to evaluate our treatment and services and the performance of our staff in caring for you. Medical information about many Health System patients may be combined to decide what additional services the Health System should offer, what services are not needed, and whether certain new treatments are effective. Information may also be disclosed to doctors, nurses, technicians, medical students, and other Health System personnel for review and learning purposes. We may also combine the medical information we have with medical information from other hospitals to compare our performance and see where improvements can be made in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and healthcare delivery without learning the identities of specific patients. We may disclose information about you for another hospital’s health care operations if you also have received care at that hospital. We may also include your health information in registry databases to evaluate treatment and outcomes at a state and national level. We may contact you to determine how satisfied you are with our services. We may contract with vendors and outside agencies to provide care and/or to assist in collecting information to assess and improve our services. We may also disclose information to accrediting agencies which review hospital operations to ensure quality of care.

Treatment Alternatives. We may use and disclose medical information to inform you of or recommend different ways to treat you.

Health-Related Benefits and Services. We may use and disclose medical information to inform you of health related benefits or services that may be of interest to you. We may also contact you to provide appointment reminders.

Fundraising Activities. We may contact you in an effort to raise money for the Health System and its non-profit patient care programs. We would only use your name, address and phone number. If you do not want the Health System to contact you to advance its philanthropic efforts, you may restrict use of your information for this purpose. Your choice to opt out of fundraising communications in no way will affect your right to receive treatment by the Health System.

Health System Directory. Unless you object, we may include certain limited information about you in the Health System directory while you are a patient at the Health System. This information may include your name, location in the Health System, your general condition (e.g., fair, stable, etc.), and your religious affiliation. The directory information, except for your religious affiliation, may also be released to anyone who asks for you by name. Your religious affiliation may be given to a member of the clergy only, such as a priest or rabbi, even if they don’t ask for you by name. This is so your family, friends, and clergy can visit you and generally know how you are doing. If you do not want anyone to know directory information about you, if you want to limit the amount of directory information that is disclosed, or if you want to limit who gets directory information, this type of information may be restricted from being released.
Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care. This includes persons named in any durable health care power of attorney or similar document provided to us. We may also give information to someone who helps pay for your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. If you are not present or cannot agree or object, we will use our professional judgment to decide whether it is in your best interest to release relevant information to someone who is involved in your care or to an entity assisting in a disaster relief effort. You may restrict sharing of your health status with someone who is involved in your care or for disaster relief efforts.

Psychotherapy Notes – We may use or disclosure your psychotherapy notes for treatment, payment and health care operations.  This may include the use or disclosure of your psychotherapy notes for training programs in mental health services, in the defense of a legal action, or for the oversight of the originator of the psychotherapy notes.  For all other uses or disclosures of your psychotherapy notes we will obtain your authorization.

Marketing – We will obtain your authorization before we use or disclose your health information for marketing, except we may use your information to have a face-to-face discussion about a service or to provide you with a gift of nominal value.

Authorization Required to Sell Your Health Information – If we sell your health information, we will first obtain your authorization.

Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process. However, we may disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the Health System. We will always ask for your specific permission if the researcher will have access to your name, address, or other information that reveals who you are, or will be involved in your care at the Health System.

USES AND DISCLOSURES WE MAY MAKE WITHOUT YOUR SPECIFIC AUTHORIZATION

As Required By Law. We will disclose medical information about you when required to do so by federal, state, or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. However, any disclosure would only be to someone able to help prevent the threat.

SPECIAL SITUATIONS

 Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye, or tissue transplantation, or to an organ donation bank as necessary to facilitate organ or tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority. We may use and disclose to components of the Department of Veterans Affairs medical information about you to determine whether you are eligible for certain benefits.

Workers’ Compensation. We may release medical information about you for Workers’ Compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:

• To prevent or control disease, injury, or disability.
• To report deaths.
• To report reactions to medications or problems with products; to notify people of recalls of products they may be using.
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
• To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health-care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release medical information if asked to do so by a law enforcement official:

• In response to a court order, subpoena, warrant, summons, or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person.
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement.
• About a death we believe may be the result of criminal conduct.
• About criminal conduct at the Health System.
• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description, or location of the person who committed the crime.

Coroners, Medical Examiners, and Funeral Directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about deceased patients of the Health System to funeral directors as necessary to carry out their duties upon the request of the patient’s family.

National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons, foreign heads of state, or to conduct special investigations.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; (3) for the safety and security of the correctional institution; or (4) to obtain payment for services provided to you.

OTHER USES AND DISCLOSURE OF YOUR HEALTH INFORMATION

Authorization
Other uses and disclosures of health information not covered by this Notice or the laws that apply will be made only with your written permission. If you provide our facilities with an authorization to use and disclose health information about you, you may revoke that permission at any time by sending a request in writing to the facility’s Health Information Management Department or Privacy Officer. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to you. If the authorization was to permit disclosure of your information to an insurance company as a condition of obtaining coverage, other laws may allow the insurer to continue to use your information to contest claims or your coverage, even after you have revoked the authorization.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

Although your medical record is the physical property of our facilities, you have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and receive a copy of medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes and other mental health records under certain circumstances.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Health Information Management (Medical Record) Department. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. If you agree, we may provide you with a summary of the information instead of providing you with access to it, or with an explanation of the information instead of a copy. Before providing you with such a summary or explanation, we first will obtain your agreement to pay the fees, if any, for preparing the summary or explanation.

We may deny your request to inspect and copy your medical information in certain very limited circumstances, such as when your physician determines that for medical reasons this is not advisable. If you are denied access to medical information, you may request that the denial be reviewed. Another   licensed healthcare professional chosen by the Health System will review your request and the denial. The person conducting the review will not be the person who denied your request. We will adhere to this person’s decision regarding your access to the records.

Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Health System. To request a correction to your medical record, you must complete a “Request for Amendment of the Medical Record” form available in the Health Information Management (Medical Records) department. Your written request will be submitted to the Health Systems Privacy officer. Under no circumstances may documentation be expunged or deleted from the medical record. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the medical information kept by or for the Health System;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete. If your request is denied, you have the right to submit a Statement of Disagreement which will be included in your medical record.

Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of some of the disclosures we made of medical information about you that were not specifically authorized by you in advance in accordance with state and federal regulations.

To request this list or accounting of disclosures, you must submit your request in writing to the Health System’s Privacy Officer. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example: on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or healthcare operations. You also have the right to request a limitation on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. A request for restriction of medical information for treatment, payment, and hospital operations must be made in writing to the Health Systems Privacy Officer.

We are not required to agree to your request unless your request pertains to not disclosing health information to a health plan for payment or operations related to services you paid in full from out of pocket. If we do agree with your request, we will comply with your request unless the information is needed to provide emergency treatment.

Right to Confidential Communications. You have the right to request to receive communications from us on a confidential basis by using alternative means for receipt of information or by receiving the information at alternative locations. For example, you can ask that we only contact you at work or by mail, or at another mailing address, besides your home address. We must accommodate your request, if it is reasonable. You are not required to provide us with an explanation as to the reason for your request. If you would like to receive copies of medical information after your treatment, you will specify the method and location that information should be sent to you.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may request a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain an additional copy of this notice, request a copy from the Health System’s Privacy Officer in writing or obtain a copy from the Health System web page www.aahs.org.

CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice throughout the Health System. The notice will contain on the first page, the effective date. In addition, each time you register at or are admitted to the Health System for treatment or healthcare services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the Anne Arundel Health System or with the Secretary of the Department of Health and Human Services. To file a complaint with the Anne Arundel Health System, contact the Patient Advocacy Office, 2001 Medical Parkway, Annapolis, MD 21401, or by phone (443) 481-4820 or TDD (443) 481-1235. To file a complaint with the Department of Health and Human Services, contact the Region III Office for Civil Rights, U.S. Department of Health and Human Services, 150 S. Independence Mall West, Suite 372, Public Ledger Building, Philadelphia, PA 19106-9111, or by phone; Main Line (215) 861-4441; Hotline (800) 368-1019; Fax (215) 861- 4431; or TDD (215) 861-4440.

OTHER USES OF MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to you. If you have any questions about this notice, please contact the Health System’s Privacy Officer at (443) 481-4130.