KINGDOM MEDICINE, PA
NOTICE OF PRIVACY PRACTICE
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 by law to maintain the privacy of your medical information and provide you with notice of our legal duties and privacy practices. We are required to abide by the terms of terms of the Notice of Privacy practices currently in effect. We reserve the right to change those terms and any changes made will be effective for all medical information we maintain. A copy of a revised notice will be available from our Privacy Officer by calling (410) 653-0366 ext. 138 or writing to KINGDOM MEDICINE, PA, Attention: Privacy Officer, 1838 Greene Tree Road, Suite 300 Pikesville, MD 21208. You may also address questions regarding our privacy practices, your privacy rights or requests for additional information regarding your privacy to this person.
We may use and disclose your medical information for specific reasons:
* Treatment: We may provide your doctors and other health care providers with the results of the diagnostic exams we perform. We may contact your before the exam to remind you of your appointment or to talk with you about preparing for the exam.
* Payment: We will bill your insurance company, you directly, or another person that may be responsible for payment of your account. We may need to contact your health plan to see if the will pay for exams your doctor has ordered.
* Health Care Operations: We routinely review past exams performed to maintain quality assurance goals. That means that we may select your chart for review. We may also select your billing information for review by our internal compliance department of by external auditors.
Disclosures without Authorization
We may use and disclose medical information about you, without your specific authorization
* Disclosures Required by Law: We may be required by federal, state, or local law to disclose your medical information.
* Public Health Activities: We may disclose your medical information to a public agency, such as the Food and Drug Administration (FDA), if you experience an adverse effect from any of the drugs, supplies or equipment we use.
* Victim of Abuse, Neglect or Domestic Violence: We may be required to disclose your medical information if we feel that you have been abused or neglected.
* Health Oversight Activities: We may be required to disclose your medical information to Medicare or a related agency if they select your case for review.
* Judicial and Administrative Proceeding: We may have to disclose your medical information if we receive a subpoena from a judge or administrative tribunal.
* Law Enforcement: We may have to disclose your medical information in conjunction with a criminal trial.
* Serious Threats to Health or Safety: We may be required to disclose your medical information if in our opinion doing so will help avert serious threats to the public.
* Military Personnel: We may disclose your medical information to the appropriate command authorities.
* Worker’s Compensation: We may disclose your medical information to comply with laws regarding worker’s compensation.
You have certain rights with respect to your medical information.
* Requesting Restrictions: You may ask us to limit our use or disclosure of your protected health information. We are not required to agree to your request, but if we agree to it, we will abide by your request except as required by law, in emergencies, or when the information is necessary to treat you. Your request must: 1) be in writing 2) describe the information that you want restricted 3) state if the restrictions is to limit our use or disclose, and 4) state to whom the restriction applies.
* Confidential Communications: You may ask that we communicate with you in a particular way, or at a certain location, to maintain your confidentiality. Your request must be in writing and must tell us how you intend to satisfy your financial responsibility and specify an alternate way that we can contact you confidentially. You do not have to give a reason for your request.
* Inspect and Copy: You may request access to inspect and copy your medical information maintained in our records, including medical and billing records. Your request must be in writing. We will act on your request within 21 days after we get it. If we must deny your request we will send you a written denial. If this happens, you may request review of denial. We may charge you a fee for this service.
* Amendment: You may ask us to amend your health information if you believe that it is incorrect or incomplete. Your request must be in writing and must include a reason to support the amendment. Your request may be denied if we believe that the information is complete and accurate, if the information is not part of the medical information that you would be permitted to inspect or copy, or if we did not create the information.
* Accounting Disclosures: You may request a list of disclosures that we have made of your medical information over the previous six (6) years. You may not request an accounting for dates of service prior to April 14, 2003. Your first request within 12-month period is free, but we may charge for additional lists within the same 12-month period.
* Paper Copy of This Notice: You are entitled to receive a paper copy of our Notice of Privacy Practices by using the contact information supplied on the first page.
* File A Complaint: If you believe that we have violated your privacy rights, you may file a complaint directly with us using the contact information on the first page. You may also file a complaint with the Secretary of the Department of Health and Human Services. You will not be penalized for complaining.
* Provide an Authorization for Other uses and Disclosures: We will request your written authorization for uses and disclosures of your medical information that are not identified in this notice or permitted by law. You may revoke your authorization at any time in writing.
ACKNOWLEDGEMENT OF RECEIPT
By signing this form, you acknowledge receipt of the Kingdom Medicine, PA Notice of Privacy Practice. Our Notice of Privacy Practice provides information about how we may use and disclose your protected health information. We encourage you to read it in full.
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