Understanding Your Health and Record Information
Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is created. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a basis for planning care and treatment and serves as a means of communication among the many health professionals who contribute to your care.
Understanding what is in your record and how your health information is used helps you to ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.
Your Health Information Rights
Unless otherwise required by law, your health record is the physical property of the healthcare practitioner or facility that compiled it; the information belongs to you. You have the right to request a restriction on certain uses and disclosures of your information, and request amendments to your health record. This includes the right to obtain a paper copy of the notice of information practices upon request, inspect, and obtain a copy of your health record. You may obtain an accounting of disclosures of your health information, request communications of your health information by alternative means or at alternative locations, revoke your authorization to use or disclose health information except to the extent that action has already been taken.
This organization is required to maintain the privacy of your health information, and in addition, provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you. This organization must abide by the terms of this notice, notify you if we are unable to agree to a requested restriction, accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you have provided. If we maintain a website that provides information about our customer services or benefits we will post our new notice on that Web site. We will not use or disclose your health information without your authorization, except as described in this notice.
Examples of Disclosures for Treatment, Payment, and Health Operations
We will use your health information for treatment. For example: Information obtained by a healthcare practitioner will be detailed in your record and used to determine the course of treatment that should work best for you. By way of example, your physician will document in your record their expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations (example varies by practitioner type). We will also provide your other practitioners with copies of various reports that should assist them in treating you.
We will use your health information for payment. For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
We will use your health information for regular health operations. For example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.
- Business Associates: There may be some services provided in our organization through contracts with Business Associates. Examples include physician services in the emergency department and radiology, certain laboratory tests, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose some or all of your health information to our Business Associate so that they can perform the job we have asked them to do. To protect your health information, we require the Business Associate to appropriately safeguard your information.
- Directory (inpatient settings): Unless you notify us that you object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name.
- Notification: We may use or disclose information to notify, or assist in notifying, a family member, personal representative, or another person responsible for your care, your location, and general condition.
- Communication with family: Health professionals, using their best judgment, may disclose to a family member, other relatives, close personal friends or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.
- Research (inpatient): We may disclose information to researchers, when an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information, has approved their research.
- Funeral directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties.
- Organ procurement organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
- Marketing: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
- Fundraising: We may contact you as part of a fundraising effort.
- Food and Drug Administration (FDA): As required by law, we may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs or replacement.
- Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
- Public health: As required by law, we may disclose your health information to public health or legal authorities charged with tracking births and deaths, as well as with preventing or controlling disease, injury, or disability.
- Correctional institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals. An inmate does not have the right to the Notice of Privacy Practices.
- Law enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a workforce member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.
- Notice of Privacy Practices availability: This notice will be prominently posted in the office where registration occurs and patients will be provided with a hard copy.
- Modification & Amendment: This notice may be modified or amended by other documents, upon notification from your healthcare provider.
- Effective Date: This notice will be effective from April 14, 2003.
A Patient’s Rights
As a patient being treated in our office, you have a right to:
- Respectful care given by competent personnel
- Consideration of your privacy concerning your own medical care
- The name of all physicians and/or staff directly assisting in your care
- Have medical records pertaining to your medical care treated as confidential, except as required by law or third party contractual agreement
- Know what rules and regulations in our practice apply to your conduct as a patient
- Expect emergency procedures to be implemented without delay
- If there is a need to transfer you to another facility, the responsible person and the facility will be notified of your condition prior to your arrival
- Good quality care and high professional standards that are continually maintained and reviewed
- Full information in layman’s terms concerning diagnosis, treatment, prognosis, and possible complications
- Provide an informed consent to the physician prior to the start of the procedure
- Be advised of participation in a medical care research program or donor program. (You will be asked to give your informed consent prior to participation in such a program and you may refuse to continue in a program that you have previously given informed consent to participate in.)
- Refuse drugs or procedures and have a physician explain the medical consequences of your refusal
- Medical and nursing services without discrimination based upon age, race, color, religion, national origin, handicap, disability or source of payment
- Have access to an interpreter whenever possible
- Access to all information contained in your medical record unless access is specifically restricted by your attending physician for medical reasons or is prohibited by law
- Expect good management techniques to be implemented that consider effective use of your time and to avoid unnecessary discomfort
- Examine and receive a detailed evaluation of your bill
- Be informed at your request of your provider’s credentials
We recognize that you have a choice for healthcare services, and we are grateful that you have chosen us as your provider.
At Capital Women’s Care, we offer counseling and educational services designed specifically for adolescents. Areas of focus include contraception, prevention of STDs, and prevention of date rape.
The Health Insurance Portability and Accountability Act, known as HIPAA, ensures and protects your right to confidentiality of your personal health information. For more information about HIPAA, visit the US Department of Health & Human Services website.
Parents generally have the right to make health care decisions for their children and so are, by default, considered the personal representatives for decisions about their children’s protected health information (PHI) access, use, and disclosure. The general principle used by HIPAA’s Privacy Rule is simple: if a person has a right to make a health care decision, then he or she has the right to control information associated with that decision. However, as a minor, your PHI is subject to three important general exceptions:
- You control your PHI that is associated with treatment that does not first require parental consent. Examples: HIV testing, prenatal care and mental health services.
- Your parents do not control PHI when a court determines or other law authorizes someone other than a parent to make treatment decisions for you.
- Your parents do not have rights to your PHI in cases where they have agreed to a confidential relationship between you and a health care provider.
Maryland State Law for Medical Treatment of a Minor § 20-102. Treatment for health-related problems.
(a) Minor who is married or parent — A minor has the same capacity as an adult to consent to medical treatment if the minor:
- Is married; or
- Is the parent of a child.
(b) Emergency treatment — A minor has the same capacity as an adult to consent to medical treatment if, in the judgment of the attending physician, the life or health of the minor would be affected adversely by delaying treatment to obtain the consent of another individual.
(c) Consent for specific treatment — A minor has the same capacity as an adult to consent to:
- Treatment for or advice about drug abuse;
- Treatment for or advice about alcoholism;
- Treatment for or advice about venereal disease;
- Treatment for or advice about pregnancy;
- Treatment for or advice about contraception other than sterilization;
- Physical examination and treatment of injuries from an alleged rape or sexual offense;
- Physical examination to obtain evidence of an alleged rape or sexual offense; and
- Initial medical screening and physical examination on and after admission of the minor into a detention center.
(c-1) Capacity to refuse treatment — The capacity of a minor to consent to treatment for drug abuse or alcoholism under subsection (c) (1) or (2) of this section does not include the capacity to refuse treatment for drug abuse or alcoholism in an inpatient alcohol or drug abuse treatment program certified under Title 8 of this article for which a parent or guardian has given consent.
(d) Consent to psychological treatment — A minor has the same capacity as an adult to consent to psychological treatment as specified under subsection (c) (1) and (2) of this section if, in the judgment of the attending physician or a psychologist, the life or health of the minor would be affected adversely by delaying treatment to obtain the consent of another individual.
(e) Liabilities — A physician, psychologist, or an individual under the direction of a physician or psychologist who treats a minor is not liable for civil damages or subject to any criminal or disciplinary penalty solely because the minor did not have capacity to consent under this section.
(f) Disclosure — Without the consent of or over the express objection of a minor, the attending physician, psychologist or, on advice or direction of the attending physician or psychologist, a member of the medical staff of a hospital or public clinic may, but need not, give a parent, guardian, or custodian of the minor or the spouse of the parent information about treatment needed by the minor or provided to the minor under this section, except information about an abortion.
[An. Code 1957, art. 43, §§ 135, 135B; 1982, ch. 21, § 2; 1992, chs. 494, 495; 1994, ch. 175; 1995, ch. 473; 2001, ch. 284.]
HIPAA Use & Disclosure Form