OPEN 7 DAYS A WEEK
410-543-2020
| Notice to Patients of Privacy Practices |
This notice describes how medical information about you may be used and
disclosed. We are required by law to protect the privacy of your protected
health information. This document also explains how you can gain access to
your medical information and who to contact should you have any complaint.
Please read this
document carefully and sign the form to acknowledge you have received this
notice.
A. The general consent for release of medical records you sign authorizes
Salisbury Immediate Care & Injury Center to disclose the information in your
medical record for treatment, payment, and health care operations:
B. You may be asked to sign a specific authorization for release of medical
records, which will authorize us to make a specific disclosure that is not
covered under section A above. The specific information, the entity to whom it
will be disclosed, and the purpose for which it will be used will be
documented for your review before signing.
C. You may revoke any consent or authorization provided to us by giving a
written notice of revocation.
D. We may be required by law to disclose your records that you have not
authorized. Examples of these situations include but are not limited to,
complying with workers compensation laws, receiving a subpoena for the
records, or if public responsibility requires disclosure, e.g, to protect public
health. We will keep all
disclosures of your medical records to the minimum necessary.
E. Your rights regarding health information about you:
information and if you believe that your rights have been violated, you may
complain to the Secretary of the U.S. Department of Health and Human
Services or complain to us by calling 410-543-2020, or by writing to us with
details (email: info@sbyimmediatecare.com). Please ask to speak to our
facility manager at our office. We will not retaliate in any way against a patient
for making a complaint.
G. We reserve the right to change our privacy practices and to make new
policies effective for all protected health information that we maintain. If we
should do so, we will issue an updated "notice to patients" to all of our
patients.
disclosed. We are required by law to protect the privacy of your protected
health information. This document also explains how you can gain access to
your medical information and who to contact should you have any complaint.
Please read this
document carefully and sign the form to acknowledge you have received this
notice.
A. The general consent for release of medical records you sign authorizes
Salisbury Immediate Care & Injury Center to disclose the information in your
medical record for treatment, payment, and health care operations:
- For the purpose of providing, coordinating, or managing your
treatment and related services. Your information may be shared with
employees and contractors of the provider, or with other health care
providers who are treating you or consulting in your care.
For the purpose of arranging payment for your care. Your information
may be shared with your insurer or other third party payor who is
responsible for paying all or part of the cost for your care. This may
include certain activities your health insurance plan or workers
compensation insurer requires before it approves or pays for health
care services we recommend.
For the purpose of health care operations. We may use and disclose
information that is necessary for our business operations, e.g,
internal quality assessments, contacting other health care providers
about treatment alternatives. We may use information about you to
remind you by telephone, letter, or postcard of an appointment for
treatment of medical care or to notify you of a diagnostic test result.
B. You may be asked to sign a specific authorization for release of medical
records, which will authorize us to make a specific disclosure that is not
covered under section A above. The specific information, the entity to whom it
will be disclosed, and the purpose for which it will be used will be
documented for your review before signing.
C. You may revoke any consent or authorization provided to us by giving a
written notice of revocation.
D. We may be required by law to disclose your records that you have not
authorized. Examples of these situations include but are not limited to,
complying with workers compensation laws, receiving a subpoena for the
records, or if public responsibility requires disclosure, e.g, to protect public
health. We will keep all
disclosures of your medical records to the minimum necessary.
E. Your rights regarding health information about you:
- You have the right to inspect a copy your health information. If you feel
that the health information we have about you is incomplete or
inaccurate, you have the right to request an amendment to your
medical records. The request must be made in writing with the
reason that supports your request. If we do not agree with your
request, you have the right to ask that your statement be place in the
medical record.
You have the right to find out how your health information is used and
to whom it is disclosed. You may request an accounting of your
medical record disclosures made by us except for disclosures made
for treatment, payment, and health care operations covered in
Section A.
information and if you believe that your rights have been violated, you may
complain to the Secretary of the U.S. Department of Health and Human
Services or complain to us by calling 410-543-2020, or by writing to us with
details (email: info@sbyimmediatecare.com). Please ask to speak to our
facility manager at our office. We will not retaliate in any way against a patient
for making a complaint.
G. We reserve the right to change our privacy practices and to make new
policies effective for all protected health information that we maintain. If we
should do so, we will issue an updated "notice to patients" to all of our
patients.
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