Calvert Memorial Hospital Privacy Notice - Effective Date: 04/14/03
"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"

Calvert Memorial Hospital uses medical information about you for treatment, to obtain payment, to evaluate the quality of care you receive, and other administrative and operational purposes. If you have any questions about this notice, please contact our Privacy Officer at the address located at the end of this document.

WHO WILL FOLLOW THIS NOTICE
This notice describes Calvert Memorial Hospital's practices regarding the use of your Protected Health Information (PHI) and that of:

Any health care professional authorized to enter information into your hospital chart or medical record.

All departments and units of the hospital, clinics or doctor's offices you may visit.

Any member of a volunteer group we allow to help you while you are in the hospital.

All employees, staff and other personnel who may need access to your information.

All entities, sites and locations of Calvert Memorial Hospital follow the terms of this notice. In addition, these entities, sites and locations may share medical information with each other for treatment, payment or health care purposes described in this notice.

OUR PLEDGE REGARDING MEDICAL INFORMATION:
We understand that medical information about you and your health is protected.

Safeguarding your Protected Health Information (PHI) is important.

CMH creates a record of the care and services you receive.

CMH needs this record to provide you with quality care and to meet certain legal requirements.

This notice applies to all of the records of your care generated by Calvert Memorial Hospital, whether made by health care professionals or other personnel.

This notice will tell you about the ways in which CMH may use and disclose Protected Health Information (PHI) about you. We also describe your rights and certain obligations we have regarding the use and disclosure of your (PHI).

WE ARE REQUIRED BY LAW TO:
Keep your Protected Health Information private.

Give you this notice of our legal duties and privacy practices with respect to your Protected Health Information.

Follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following categories describe different ways that we may use and disclose your Protected Health Information (PHI). For each category we will try to give some examples. Not every use or disclosure in a category will be listed.

FOR TREATMENT
We may use your PHI to provide you with medical treatment or services. We may disclose protected health information about you to doctors, nurses, technicians, other hospital personnel, students and volunteers who are involved in taking care of you.

For example, a doctor treating you for a broken leg 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 you have diabetes so that we can arrange for special meals.

FOR PAYMENT
We may use and disclose PHI about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party.

For example, your insurance may require copies of your record as proof for the treatment you received so they will pay us or reimburse you for the treatment.

We may also use and disclose PHI about you to obtain prior approval or to determine if your insurance will cover the treatment.

FOR HEALTH CARE OPERATIONS
We may use and disclose PHI about you for administrative and operational purposes. This is done to make sure that all of our patients receive quality care.

For example, we may use your PHI to review our treatment and to evaluate the performance of our staff in caring for you.

OTHER DISCLOSURES
Business Associates. There are some services provided at CMH through contracts with business associates. Examples may include billing companies, record storage companies and medical transcription companies. When these services are contracted we may disclose your PHI to our business associates so they can perform the job we have asked them to do. To protect your PHI we require our business associates to appropriately safeguard our Protected Health Information.

Appointment Reminders. We may use and disclose your PHI to remind you that you have an appointment for treatment or medical care.

Treatment Alternatives. We may use and disclose your PHI to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services. We may use and disclose your PHI to tell you about health-related benefits, services, fairs, workshops and screenings that may be of interest to you.

Hospital Directory. We may include certain limited information about you in the hospital directory while you are a patient at the hospital. This information may include your name, your doctor, your location in the hospital, your general condition (e.g.: fair, stable, etc.) and your religious affiliation. This directory information, except for your religious affiliation, may also be released to people who ask for you by name. This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don't ask for you by name.

If you do not wish to be included in this directory, it is important that you inform the hospital staff when you register.

Individuals Involved in Your Care or Payment for Your Care. CMH may release medical information about you to a family member, other relative, friend or any other person you identify who is involved in your medical care. We may also give information to someone who helps pay for your care. CMH may also tell your family or friends your condition and that you are in the hospital. In addition, we may disclose your PHI to an entity assisting in a disaster relief effort or in a response to a terrorist attack, so that your family can be notified about your condition, status and location.

Research. We may use or disclose PHI about you to a researcher or research organization if our Institutional Review Committee has reviewed and approved the research proposal, after establishing protocols to ensure the privacy of your PHI.

As Required By Law. CMH 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. CMH may use and disclose your PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone or some entity that may be able to help prevent the threat.

Fund-raising Activities. CMH may use your PHI in an effort to raise money for the hospital and its operations. We may disclose your PHI to a foundation related to the hospital so that the foundation may raise money for the hospital. We only would release contact information, such as your name, address and phone number.

SPECIAL SITUATIONS
Organ and Tissue Donation. Consistent with applicable law, CMH may release your PHI to organizations that handle organ procurement, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation, transportation and/or transplantation.

Workers' Compensation. CMH may release your PHI to workers' compensation or similar programs.

FDA. CMH may disclose to the Food and Drug Administration (FDA) your PHI relative to any adverse events with respect to food, supplements, products and product defects, post-marketing surveillance information to enable a product recall, repair or replacement.

Public Health Risks. As required by law, CMH may disclose your PHI to public health or legal authorities charged with preventing or controlling disease (s), injury or disability. These activities generally include the following:

To prevent or control disease, injury or disability;

To report births and deaths;

To report birth defects;

To report child abuse or neglect;

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.

Health Oversight Activities. CMH may disclose your PHI 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. CMH may disclose your PHI in response to a subpoena, discovery request, court order or other lawful order from a court.

Law Enforcement. CMH may release your PHI if asked to do so by a law enforcement official as part of a law enforcement activity. These include:

In investigations of criminal conduct;

In investigations or searches for victims of crime (when unable to obtain a patient's consent;

In response to court orders, subpoenas, warrants, summons or in emergency circumstances;

To identify or locate a suspect, fugitive, material witness or missing person;

Investigation of a death CMH may believe is a result of criminal conduct;

Investigation of criminal conduct at CMH;

In emergency circumstances to report a crime, location of a crime or victims, or the identity, description or location of a person who committed the crime and

When required to do so by law.

Coroners, Medical Examiners and Funeral Directors. CMH may release your PHI to a forensic investigator, 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 your PHI to funeral directors as necessary to carry out their duties.

Specialized Government Functions. We may use or disclose protected health information about you to specialized government functions, such as protection of public officials, national security and intelligence activities, or reporting to various branches of the armed services.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, CMH may release your PHI 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; or (3) for the safety and security of the correctional institution.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION (PHI)
You have the following rights regarding the Protected Health Information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy PHI that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes (i.e. notes from a private, group, joint or family counseling session recorded by a mental health professional such as a psychiatrist, clinical psychologist or clinical social worker).

To inspect and copy the PHI that may be used to make decisions about you, you must submit your request in writing to our Privacy Officer at the address on the last page. 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.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your PHI, you may request that the denial be reviewed. Another licensed health care professional chosen by Calvert Memorial Hospital will review your request and the denial. The person conducting the review will not be the person who denied your request. CMH will comply with the outcome of the review.

Right to Amend. If you feel that your PHI is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as your PHI is kept by Calvert Memorial Hospital.

To request an amendment, your request must be made in writing and submitted to our Privacy Officer at the address located at the end of this document. In addition, you must provide a reason that supports your request.

CMH 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 Calvert Memorial Hospital;

Is not part of the information which you would be permitted to inspect and copy;

Is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of certain disclosures CMH made of your PHI.

To request an accounting of disclosures, you must submit your request in writing to our Privacy Officer at the address located at the end of this document.

Your request must state the time frame you are interested in examining. This period cannot be any longer than six (6) years and may not include any dates prior to April 13, 2003.

CMH is required to give you an accounting of any release of your PHI other than for treatment, payment or operations.

The first accounting of your disclosures list in a twelve (12) month period is free. Additional requests will be billed to you. CMH will inform you of the costs associated with providing you with the requested list and ask if you still want it.

Right to Request Restrictions. You have the right to request a restriction or limitation on the PHI CMH uses or discloses for treatment, payment or health care operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.

CMH is not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing to our Privacy Officer at the address listed at the end of this notice. In your request, you must tell us:

(1) What information you want to limit;

(2) Whether you want to limit our use, disclosure or both; and

(3) To whom you want the limits to apply.

Right to Request Confidential Communications. You have the right to request that CMH communicates with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to our Privacy Officer at the address located at the end of this document. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how and/or where you wish to be contacted.

Right to a Paper Copy of This Notice. You have the right to a paper 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 a paper copy of this notice, please contact our Privacy Officer at the address or phone number located at the end of this document.

CHANGES TO THIS NOTICE
CMH reserves the right to change our privacy practices and this notice. We reserve the right to make the revised or changed notice effective for your PHI we already have as well as any information we receive in the future. We will post a copy of the current notice. The notice will contain on the first page, the effective date of the Privacy Notice.

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer at Calvert Memorial Hospital. The complaint must be in writing and sent to the address provided at the end of this notice. Additionally, you may file a complaint with the Secretary of the Department of Health and Human Services.

You will not be retaliated against for filing a complaint.

OTHER USES OF YOUR PROTECTED HEALTH INFORMATION
Other uses and disclosures of your PHI not covered by this notice or the laws that apply to CMH will be made only with your written permission. If you provide us authorization to use or disclose your PHI, you may revoke that authorization, in writing, at any time. The written notices must be sent to CMH's Privacy Officer at the address located at the end of this document. If you revoke your authorization we will no longer use or disclose your PHI for the reasons covered by your written authorization. You understand that CMH is unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provided to you.

ADDITIONAL INFORMATION

PRIVACY OFFICER AT CALVERT MEMORIAL HOSPITAL:
Kenneth J. Maiorana, RHIA
Director of Medical Record Services
100 Hospital Road
Prince Frederick, MD 20678

FOR QUESTIONS REGARDING THIS NOTICE PLEASE LEAVE A MESSAGE AT:
Telephone: 410-535-8282

FUND-RAISING OFFICE:
Calvert Memorial Hospital Foundation, Inc.
P.O. Box 2127
Prince Frederick, MD 20678