NOTICE OF PRIVACY PRACTICES
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. This provides only a summary of our privacy policy; further details are provided upon request.
USES AND DISCLOSURES: We use health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive. Continuity of care is part of treatment and your records may be shared with other providers to whom you are referred. Information may be shared by paper mail, electronic mail, fax or other methods. We may use or disclose identifiable health information about you without your authorization in several situations, but beyond those situations, we will ask for your written authorization before using or disclosing any identifiable health information about you.
YOUR RIGHTS: In most cases, you have the right to look at or get a copy of health information about you. If you request copies, we may charge you only the normal photocopy fees. You also have the right to receive a list of certain types of disclosures of your information that we made. If you believe that information in your record is incorrect, you have the right to request that we correct the existing information.
COMPLAINTS: If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the person listed below. You also may send a written complaint to the U.S. Department of Health and Human Services. The person listed below can provide you with the appropriate address upon request.
OUR LEGAL DUTY: We are required by law to protect the privacy of your information, provide this notice about our information practices, follow the information practices that are described in this notice, and seek your acknowledgement of receipt of this notice. Before we make a significant change in our policies, we will change our notice and post the new notice in the reception area. You can also request a copy of our notice at any time. For more information, questions, or complaints about our privacy practices, contact the person listed below:
Alan H. Shikani, M.D./ Han G Sohn MD, FACS
200 East 33rd Street Professional Building Suite 631
Baltimore, Maryland 21218
Phone: 410-554-4455
I acknowledge receipt of Notice of Privacy Practices of Baltimore Medical and Surgical Associates.
Patient’s Name:_____________________________________________ Date:_____________
Signature:____________________________________________________________________
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