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.
Uses and Disclosures
Treatment. Your health information may be used by staff members or disclosed
to other health care professionals for the purpose of evaluating your
health, diagnosing medical conditions, and providing treatment. For example,
results of laboratory tests and procedures will be available in your medical
record to all health professionals who may provide treatment or who may
be consulted by staff members.
Payment. Your health information may be used to seek payment from your
health plan, from other sources of coverage such as an automobile insurer, or
from credit card companies that you may use to pay for services. For example,
your health plan may request and receive information on dates of service,
the services provided, and the medical condition being treated.
Health care operations. Your health information may be used as necessary
to support the day-to-day activities and management of Cumberland Valley Surgery Center.
For example, information on the services you received may be used to
support budgeting and financial reporting, and activities to evaluate and promote
Law enforcement. Your health information may be disclosed to law enforcement
agencies to support government audits and inspections, to facilitate
law-enforcement investigations, and to comply with government-mandated
Public health reporting. Your health information may be disclosed to public
health agencies as required by law. For example, we are required to report
certain communicable diseases to the state’s public health department.
Other uses and disclosures require your authorization. Disclosure of your
health information or its use for any purpose other than those listed above
requires your specific written authorization. If you change your mind after
authorizing a use or disclosure of your information you may submit a written
revocation of the authorization. However, your decision to revoke the authorization
will not affect or undo any use or disclosure of information that
occurred before you notified us of your decision to revoke your authorization.
Additional Uses of Information
Appointment reminders. Your health information will be used by our staff
to send you appointment reminders.
Information about treatments. Your health information may be used to
send you information that you may find interesting on the treatment and
management of your medical condition. We may also send you information
describing other health-related products and services that we believe may
interest you.
Fundraising. Unless you request us not to, we will use your name and
address to support our fundraising efforts. If you do not want to participate
in fundraising efforts, please check off the following box.
❑ Please do not use my information for fundraising purposes.
Individual Rights
You have certain rights under the federal privacy standards. These include:
◆ The right to request restrictions on the use and disclosure of your
protected health information
◆ The right to receive confidential communications concerning your
medical condition and treatment
◆ The right to inspect and copy your protected health information
◆ The right to amend or submit corrections to your protected health
information
◆ The right to receive an accounting of how and to whom your protected
health information has been disclosed
◆ The right to receive a printed copy of this notice
Cumberland Valley Surgery Center Duties
We are required by law to maintain the privacy of your protected health
information and to provide you with this “Notice of Privacy Practices.”
We also are required to abide by the privacy policies and practices that are
outlined in this notice.
Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy
policies and practices. These changes in our policies and practices may be
required by changes in federal and state laws and regulations. Upon request,
we will provide you with the most recently revised notice on any office visit.
The revised policies and practices will be applied to all protected health
information we maintain.
Requests to Inspect Protected Health Information
You may generally inspect or copy the protected health information that we
maintain. As permitted by federal regulation, we require that requests to
inspect or copy protected health information be submitted in writing. You
may obtain a form to request access to your records by contacting
Medical Records staff member or the Administrator. Your request will be reviewed
and will generally be approved unless there are legal or medical
reasons to deny the request.
Complaints
If you would like to submit a comment or complaint about our privacy
practices, you can do so by sending a letter outlining your concerns to:
Elaine Tiznado, MSN, RN
Administrator
Cumberland Valley Surgery Center
1110 Professional Court Suite 100
Hagerstown MD 21740
If you believe that your privacy rights have been violated, you should call the
matter to our attention by sending a letter describing the cause of your concern
to the same address.
You will not be penalized or otherwise retaliated against for filing a complaint.
Contact Person
The name and address of the person you may contact for further information
concerning our privacy practices is:
Elaine Tiznado, MSN, RN
Administrator
Cumberland Valley Surgery Center
1110 Professional Court Suite 100
Hagerstown MD 21740
240-420-5559
