The Urological Center, P.A.
Antietam UroSurgical Center, LLC, ASC
Antietam Center for Men's Health, LLC

Notice Of Privacy Practices

As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and how you can get access to your individually indentifiable health information.

Please review this notice carefully

A. Our Commitment To Your Privacy

• How we may use and disclose your IIHI
• Your privacy rights in your IIHI
• Our obligations concerning the use and disclosure of your IIHI

The terms of this notice apply to all records containg your IIHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or ammendment to this notice will be effective for all of your records that our practice has created maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our most current Notice at any time.

B. If You Have Questions About This Notice, Please Contact:

11110 Medical Campus Road, #228
Hagerstown, MD 21742
301-733-0022

C. We May Use And Disclose Your Individually Identifiable Health Information (IIHI) In The Following Ways

The following categories describe the different ways in which we may use and disclose your IIHI

1. Treatment. Our practice may use your IIHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your IIHI to write a prescription for you, or we might disclose your IIHI to a pharmacy when we order a perscription Many of the people who work for our practice-including, but not limited to, our doctors and nurses-may use or disclose your IIHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your IIHI to others who may assist in your care, such as your spouse, children, or parents. Finally, we may also disclose your IIHI to other health care providers for purposes related to your treatment.
2. Payment. Our practice may use and disclose your IIHI in order to bill and collect payment for the services and items you receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details reguarding your treatment to determine if your insurer will cover, or pay for, your treatment. We may also use and disclose your IIHI to obtain payment from third parties thay may be responsible for such costs, such as family members. Also, we may use your IIHI to bill you directly for services and items. We may disclose your IIHI to other health care providers and entities to assist in their billing and collection efforts.
3. Health Care Operation. Our practice may use and disclose your IIHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your IIHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activites for our practice. We may disclose your IIHI to other health care providers and entities to assist in their health care operations.
4. Appointment Reminders. Our practice may use and disclose your IIHI to contact you and remind you of an appointment.
5. Treatment Options. Our practice may use and disclose your IIHI to inform you of potential treatment options or alternatives.
6. Health-Related Benefits and Services. Our practice may use and disclose your IIHI to inform you of health-related benefits or services that may be of interest to you.
7. Release Of Information To Family/Friends. Our practice may release your IIHI to a friend or family member that is involved in your care, or who assists taking care of you. For example, a parent or guardian may ask that a babysitter take their child to the pediatrician's office for treatment of a cold. In this example, the babysitter may have access to this child's medical information.
8. Disclosures Required By Law. Our practice will use and disclose your IIHI when we are required to do so by federal, state or local law.

1. Public Health Risks. Our practice may disclose your IIHI to public health authorities that are authorized by law to collect information for the purpose of:

• maintaining vital records, such as births and deaths
• reporting child abuse or neglect
• preventing or controlling disease, injury, or disability
• notifying a person reguarding potential exposure to a communicable disease or condition
• reporting reactions to drugs or problems with products or devices
• notifying individuals if a product or device they may be using has been recalled
• notifying appropriate government agency(ies) and authority(ies) reguarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information.
• notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

    2. Health Oversight Activities. Our practice may disclose your IIHI to a health        oversight agency for activites authorized by law. Oversight activites can        include, for example, investigations, inspections, audits, surveys, licensure,        and disciplinary actions; civil, administrative, and criminal procedures or        actions; or other activites necessary for the government to monitor government        programs, compliance with civil rights laws and the health care system.

    3. Lawsuits And Similar Proceedings. Our practice may use and disclose        your IIHI in response to a court or administrative order, if you are involved in a        lawsuit or similar proceeding. We also may disclose your IIHI in response to a        discovery request, subpoena, or other lawful process by another party involved        in the dispute, but only if we have made an effort to inform you of the request        or to obtain an order protecting the information the party has requested

    4. Law Enforcement. We may release IIHI if asked to do so by a law         enforcement official:

• Reguarding a crime victim in certain situations, if we are unable to obtain the person's agreement.
• Concerning a death we believe has resulted from criminal conduct
• Reguarding criminal conduct at our offices
• In response to a warrant, summons, court order, subpoena or similar legal process
• To identify/locate a suspect, material witness, fugative or missing person
• In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)

    5. Deceased Patients. Our practice may release IIHI to a medical examiner or       coroner to identify a deceased individual or to identify the cause of death. If       necessary, we may also release information in order for the funeral directors to       perform their jobs.

    6. Organ And Tissue Donation. Our practice may release your IIHI to       organizations that handle organ, eye or tissue procurement or transplantation,       including organ donation banks, as necessary to facilitate organ or tissue       donation and transplantation if you are an organ donor.

    7. Research. Our practice may use and disclose your IIHI for research purposes       in certain limited circumstances. We will obtain your written authorization to       use your IIHI for research purposes except when an Institutional Review Board       or Privacy Board has determined that the waiver of your authorization satisfies       the following: (i) the use or disclosure involves no more than a minimal risk to       your privacy based on the following: (A) an adequate plan to protect the       identifiers from improper use and disclosures; (B) an adequate plan to destroy       the identifiers at the earliest opportunity consists with the research (unless       there is a health or resarch justification for retaining the identifiers or such       retention is otherwise required by law); and (C) adequate written assurances       that the PHI will not be re-used or disclosed to any other person or entity       (except as required by law) for authorization oversight of hte research study, or       for other research for which the use or disclosure would otherwise be       permitted; (ii) the research could not practicably be conducted without the       waiver; and (iii) the research could not practicably be conducted without       access to and use of the PHI.

    8. Serious Threats To Health Or Safety. Our practice may use and disclose       your IIHI when necessary to reduce or prevent a serious threat to your health       and safety or the health and safety of another individual or the public. Under       these circumstances, we will only make disclosures to a person or       organization able to help prevent the threat.

    9. Military. Our practice may disclose your IIHI if you are a member of U.S. or       foreign military forces (including veterans) and if required by the appropriate       authorities.

    10. National Security. Our practice may disclose your IIHI to federal officials for       intelligence and national security activities authorized by law. We also may       disclose your IIHI to federal officials in order to protect the President, other       officials or foreign heads of state, or to conduct investigations.

    11. Inmates. Our practice may disclose your IIHI to correctional institutions or       law enforcement officials if you are an inmate or under the custody of a law       enforcement official. Disclosure for these purposes would be necessary: (a) for       the institution to provide health care services to you, (b) for the safety and       security of the institution, and/or (c) to protect your health and safety or the       health and safety of other individuals.

    12. Workers' Compensation. Our practice may release your IIHI for workers'       compensation and similar programs.

E. Your Rights Regarding Your IIHI

You have the following rights regarding the IIHI that we maintain about you:

1. Confidential Communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to Medical Records Department specifying the request method of contact, or the location where you wish to contacted. Our practice will accommodate a reasonable request. You do not need to give a reason for your request.
2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your IIHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your IIHI to only certain individuals involved in your care or the payment of your care, such as family memebers and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when information is necessary to treat you. In order ro request a restriction in our use or disclosure of your IIHI, you must make a request in writting to the Medical Records Department. Your request must be described in a clear and concise fashion:
   
      (a) the information you wish restricted;
      (b) whether you are requesting to limit our practice's use, disclosure or                 both; and
      (c) to whom you want the limits to apply.
   
3. Inspection and Copies. You have the right to inspect and obtain a copy of the IIHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writting to the Medical Records Department in order to inspect and/or obtain a copy of your IIHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.
4. Amendment. You may ask us to amend your health information if you believe it is incorret or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request and amendment, your request must be made in writting and submitted to your physician, 301-733-0022. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writting. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the IIHI kept by or for the practice; (c) not part of the IIHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.
5. Accounting Of Disclosures. All of our patients have the right to request an "accounting of disclosures." An "accounting of disclosures" is a list of certain non-routine disclosures our practice has made of your IIHI for non-treatment, non-payment or non-operations purposes. Use of your IIHI as part of the routine patient care in our practice is not required to be documented. For example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to the Medical Records Department. All requests for an "accounting of disclosures" must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice will charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, you may withdraw your request before you incur any costs.
6. Right To A Paper Copy Of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact the Clerical Department.
7. Right To File A Complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact 301-733-0022. All complaints must be submitted in writting. You will not be penalized for filling a complaint.
8. Right To Provide An Authorization For Other Uses And DisclosuresOur practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your IIHI may be revoked at any time in writting. After you revoke your authorization, we will no longer use or disclose your IIHI for the reasons described in the authorization. Please note, we are required to retain records of your care.

Again, if you have any questions regarding this notice or our health information privacy policies, please contact 301-733-0022

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