THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Effective Date: January 1, 2018
About This Notice
We are required by law to maintain the privacy of Protected Health Information and to give you this Notice explaining our privacy practices with regard to that information. You have certain rights – and we have certain legal obligations – regarding the privacy of your Protected Health Information, and this Notice also explains your rights and our obligations. We are required to abide by the terms of the current version of this Notice.
What is Protected Health Information?
“Protected Health Information” is information that individually identifies you and that we create or get from you or from another health care provider, health plan, your employer, or a health care clearinghouse and that relates to (1) your past, present, or future physical or mental health or conditions, (2) the provision of health care to you, or (3) the past, present, or future payment for your health care.
Who Will Follow This Notice?
All MFA healthcare providers, employees, residents, physicians, trainees and other members of the MFA workforce will follow this notice.
How We May Use and Disclose Your Health Information:
We typically use or disclose your health information in the ways described below, although not every use or disclosure falling within each category is listed:
Treatment. We use and disclose your health information to provide your medical treatment. For example, your physician may review your record or may confer with another non-MFA physician or provider about your care.
Payment. We use and disclose your health information so that we can bill and collect payment from you, a health plan, or a third party. For example, we may need to give your health plan information about a service provided to you so your health plan will pay us or reimburse you for the service.
Health Care Operations. We use and disclose your health information to run our practice, improve your care, and contact you when necessary. For example, we may use and disclose your health information to review our treatment and services, to evaluate the performance of our staff in caring for you, or to other persons for educational and learning purposes.
Additional Uses and Disclosures:
We are allowed to use and disclose your health information in other ways, as long as we comply with the law related to those uses or disclosures. We may use and disclose your health information to:
- Comply with federal, state, or local laws that require disclosure;
- Assist in public health activities, such as tracking diseases or medical devices;
- Inform authorities to protect victims of abuse or neglect;
- Comply with Federal and state health oversight activities, such as fraud investigations;
- Respond to law enforcement officials or to judicial orders, subpoenas, or other process;
- Inform coroners, medical examiners, and funeral directors of information necessary for them to fulfill their duties;
- Facilitate organ and tissue donation or procurement;
- Avert a serious threat to health or safety;
- Assist in specialized government functions such as national security, intelligence, and protective services;
- Inform military and veteran authorities if you are an armed forces member (active or reserve);
- Inform a correctional institution if you are an inmate;
- Inform workers’ compensation carriers or your employer if you are injured at work;
- Perform research, under certain circumstances, we may use and disclose PHI about you for research purposes. All research projects, however, are subject to a special approval process before your PHI may be used or disclosed;
- Work with Business Associates, we may disclose your PHI to third parties who perform services on our behalf and who have provided assurances that they will safeguard your PHI.
- Contact you to remind you that you have an appointment for treatment or medical care, or to contact you to tell you about possible treatment options and health related benefits and services that may be of interest to you.
Uses and Disclosures for Which You Can Opt Out:
In the instances listed below we may use or disclose your health information unless you object.
Individuals Involved in Your Care or Payment for Your Care. We may disclose your health information to a family member, close friend, or any other person involved in your care or payment for that care.
Disaster Relief. We may disclose your health information to disaster relief organizations that seek your health information to coordinate your care or to notify family and friends of your location or condition in a disaster.
Fundraising Activities. We may use or disclose your PHI in order to contact you for fundraising activities. You can let us know if you do not want to be contacted again.
CRISP Participation. We have chosen to participate in the Chesapeake Regional Information System for our Patients (CRISP), a regional health information exchange serving Maryland and D.C. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. You may “opt-out” and disable access to your health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax or through their website at www.crisphealth.org. Public health reporting and Controlled Dangerous Substances information, as part of the Maryland Prescription Drug Monitoring Program (PDMP), will still be available to providers.
Obtaining Your Written Authorization:
The following uses and disclosures of your health information will be made only if you provide us with your written authorization:
• Most disclosures of psychotherapy notes
• Uses and disclosures for marketing purposes
• Sale of your health information
Other uses and disclosures not described in this Notice will be made only with your authorization. If you do provide us with your written authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer; however, this will not affect prior uses and disclosures.
• We are required by law to maintain the privacy and security of your health information.
• We will let you know if a breach occurs that compromises the privacy or security of your health information.
• We will not use or share your information other than as described in this Notice, unless you provide us with your authorization.
• If a state or District of Columbia law is applicable and is more restrictive than federal law, we will follow the more restrictive law. For example, in some cases disclosures of your mental health information may be limited unless we obtain your written permission prior to the disclosure.
The law entitles you to:
• Get an electronic or paper copy of your medical record. We will provide a copy or summary of your health information, usually within 30 days of your request. We may charge you a reasonable, cost-based fee for the copies.
• Ask us to correct your medical record. You can ask us to correct health information about you that you think is incorrect or incomplete. We may say no to your request, but we’ll tell you why in writing within 60 days.
• Request confidential communications. You can ask us to contact you in a specific way (for example home or office phone) or to send mail to a different address. We will agree to reasonable requests.
• Ask us to limit what we use or disclose. You can ask us not to use or disclose certain PHI. We are not required to agree to your request, and we may say no if it would affect your care or if we cannot reasonably comply with your request. If we agree to your request, we will comply with your request unless the information is needed to provide you with emergency treatment.
• Right to Restrict Disclosures of your PHI to your Health Plan. If you pay for a service out of pocket and in full, you may request that we not disclose information about that visit to your insurance plan and we must honor that request. However, if you want us to bill your insurance plan for any subsequent care, we may have to provide the original information to your carrier in order for us to be paid for the subsequent service. We will agree to that limitation unless the law would require us to do otherwise.
• Right to an Accounting of Disclosures. You have the right to ask for an “accounting of disclosures,” which is a list of the disclosures we made of your PHI. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice. It also excludes disclosures we may have made to you or pursuant to your authorization, for a resident directory, to family members or friends involved in your care, or for notification purposes. You can ask for a list (accounting) of the times we’ve shared your PHI for six years prior to the date you ask. The first accounting you request within a twelve (12) month period will be free. For additional accountings, we may charge you for the costs of providing the list.
• Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• Get a copy of this Notice. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.
• Right to Receive Notice of a Breach. You have the right to receive a notification, in the event that there is a breach of your unsecured PHI, which requires notification under the Privacy Rule.
If you believe that your privacy rights have been violated, you may file a complaint with The GW Medical Faculty Associates:
The GW Medical Faculty Associates
2120 L Street, NW, Suite 610
Washington, DC 20037
ALERTLINE (Anonymous Reporting): 1-855-231-0615
We will not take action against you for filing a complaint. You also may file a complaint with the Secretary of the U. S. Department of Health and Human Services at www.hhs.gov/ocr/privacy/hipaa/complaints/
The GW Medical Faculty Associates complies with applicable federal civil rights laws and healthcare laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
The GW Medical Faculty Associates does not exclude people or treat them differently because of race, color, national origin, age, disability, gender or sex.
To assist our patients and improve their care, The GW Medical Faculty Associates will provide free aids and services to people with disabilities and free language services to people whose primary language is not English.
If you require communication aids or language services, please contact the clinic where you are being seen or reach out to the Patient Experience Department at 202.677.6620 or email@example.com.
Spanish - ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-202-677-6620.
Amharic - ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-202-677-6620.
Mandarin - 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致 電 1-202-677-6620.
Changes to this Notice
We reserve the right to change privacy practices and make the new practices effective for all the information we maintain. Revised notices will be posted in our facilities, and we will offer you a copy when you receive services.
Download to Print this Notice
IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR IF YOU NEED MORE INFORMATION, PLEASE CONTACT OUR PRIVACY OFFICER:
MFA Privacy Officer Mailing Address:
2120 L Street, NW, Suite 610, Washington, DC 20037
Telephone: 202-741-3341 or Alertline at 1-855-231-0615