EFFECTIVE DATE: December 1, 2011

REVISED DATE: November 1, 2011

Carroll Hospital Center, Inc. and Affiliates

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.

Who Will Follow this Notice

This notice describes our hospital’s practices and that of:
• Any health care professional authorized to enter information into your hospital chart.
• Any member of a volunteer group we allow to help you while you are in the hospital.
• All employees and staff in all departments and units.
• Affiliates of Carroll Hospital Center, Inc. and members of the medical staff of the hospital and its affiliates may share medical information with each other for treatment, payment or health care operations purposes described in this notice.

Our Pledge Regarding Medical Information

We understand that your medical information is personal and we are committed to protecting that information. We create a record of the care you receive at the hospital. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the hospital, whether made by hospital personnel or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office or clinic.
This notice will tell you about the ways we may use and disclose your medical information as well as explain what your rights and obligations are regarding the use and disclosure of the information.

We are required by law to:
• Make sure that medical information that identifies you is kept private.
• Give you this notice of our legal duties and privacy practices with respect to medical information about you.
• Follow the terms of the notice that is currently in effect.

How We May Disclose Medical Information About You

The following categories describe different ways that we use and disclose medical information. For each category we will explain what we mean and try to give an example. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment. We may record in your medical record medical information about you and we may use this medical information to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students or other hospital personnel who are involved in taking care of you at the hospital. This information is necessary for these health care providers to determine what medical treatment you should receive. Different departments of the hospital also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and X-rays. We also may disclose medical information about you to people outside the hospital who may be involved in your medical care after you leave the hospital, such as other medical providers who will provide services that are part of your care.

For Payment. We may use and disclose medical information about you to obtain prior approval from your insurance company for services, or so that the treatment and services you receive at the hospital may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about surgery you received at the hospital so your health plan will pay us or reimburse you for the surgery.

For Health Care Operations. We may use and disclose medical information about you for hospital operations. These uses and disclosures are necessary to run the hospital and make sure that all of our patients receive quality care. For example, we may use medical information about you to evaluate our staff and services or for teaching purposes. We may also combine medical information about many hospital patients and about other hospitals to see where we can make improvements in the quality of care and services we offer.

Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at the hospital.
Treatment Alternatives and Health-Related Services. We may use and disclose medical information to tell you about, or recommend, possible treatment options, alternatives, health-related benefits or services that may be of interest to you.

Fundraising Activities. We may use information about you or disclose it to our Foundation office so they may contact you in an effort to raise money for the hospital and its operations. We only would release contact information, such as your name, address and phone number, and the dates you received treatment or services at the hospital. If you do not want the hospital to contact you for fundraising efforts, you must notify The Director of Risk and Regulatory Compliance, Carroll Hospital Center, 200 Memorial Avenue, Westminster, MD 21157 in writing.

Hospital Directory. Unless you object, 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, location in the hospital, general condition (e.g., fair, stable, etc.) and religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation also 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. This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing.

Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. In addition, we may disclose medical information about you to an entity assisting in disaster relief efforts so that your family can be notified about your condition, status and location.

Workers’ Compensation. We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Organ and Tissue Donation. If you are an organ donor, we may release medical information about you to organizations that handle organ procurement or organ, eye or tissue transplantation, or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Coroners, Medical Examiners and Funeral Directors. We may release medical information about you to a 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 medical information about patients of the hospital to funeral directors as necessary to carry out their duties.

Research. Under certain circumstances, we may use and disclose medical information about you for research purposes or to people preparing a research proposal. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, must be approved by a privacy board that has reviewed the research proposal to ensure the privacy of your medical information.

Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:
• To prevent or control disease, injury or disability.
• To report births and deaths.
• 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. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections and licensure.

To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to the health and safety of you or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

As Required by Law. We will disclose medical information about you when required to do so by federal, state or local law.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release medical information about you if asked to do so by a law enforcement official:
• In response to a court order, subpoena, warrant, summons or similar process.
• To identify or locate a suspect, fugitive, material witness or missing person.
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement.
• About a death we believe may be the result of criminal conduct.
• About criminal conduct at the hospital.
• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Military and Veterans. If you are a member of the Armed Forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.

National Security, Intelligence Activities and Protective Services. We may release medical information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law and for protective services for certain public and foreign officials.

Inmates. We may release medical information about an inmate of a correctional institution or individual in the custody of a law enforcement official to that correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect the health and safety of you or other inmates; or (3) for the safety and security of the correctional institution.

To, From and Between Business Associates. The hospital contracts with business associates to provide certain services. We may release medical information about you to our business associates, receive medical information about you from our business associates, and our business associates may share medical information about you between themselves. For example, we may disclose medical information about you to a third-party service provider responsible for billing or providing other services to us. To protect your medical information, however, the hospital requires business associates to sign contracts agreeing to appropriately safeguard such information.

To DHHS. We may disclose your medical information in response to investigations by the Department of Health and Human Services.

Health Information Exchanges. We may participate in health information exchanges to facilitate the secure exchange of your electronic health information between and among several health care providers or other health care entities for your treatment, payment or other health care operations purposes. This means we may share information we obtain or create about you with outside entities (such as hospitals, doctors’ offices, pharmacies or insurance companies) or we may receive information they create or obtain about you (such as medication history, medical history or insurance information) so each of us can provide better treatment and coordination of your health care services.

Other Uses of Medical Information

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization, except to the extent that action has already been taken by the hospital.

Your Rights Regarding Medical Information About You
You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care as provided for in the Code of Federal Regulations (C.F.R.) at 45 C.F.R. §164.524. Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to The Director of Risk and Regulatory Compliance, 200 Memorial Avenue, Westminster, MD 21157. To the extent we use or maintain this information in an electronic health record, you may request that we provide you with a copy of such information in electronic format. 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 your medical information. In certain very limited circumstances, our denial will be unreviewable. Ordinarily, however, if you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the hospital will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information as provided in 45 C.F.R. §164.526. You have the right to request an amendment for as long as the information is kept by the hospital. To request an amendment, your request must be made in writing and submitted to The Director of Risk and Regulatory Compliance, Carroll Hospital Center, 200 Memorial Avenue, Westminster, MD 21157. You must provide a reason that supports your request. We 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 or for the hospital.
• Is not part of the information which you would be permitted to inspect and copy.
• Is accurate and complete.
We will distribute your request (or a summary) with all future disclosures of information to which it relates, but only if you ask us to do so. Further, you may submit a written statement disagreeing with the denial and we will keep it on file and distribute it (or a summary) with all future disclosures of the information to which it relates.

Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures as provided in 45 C.F.R. §164.528. This is a list of certain disclosures we made of medical information about you, but does not include disclosures:
• To you or to persons involved in your health care or payment for that care.
• Pursuant to your written authorization.
• For the purpose of carrying out treatment, payment or health care operations.
• That are incidental to another permissible use or disclosure.
• For disaster relief, national security or intelligence purposes.
• To correctional institutions or law enforcement officers who have you in custody at the time of the disclosure.
• As part of a limited data set.
• To a health oversight agency or law enforcement official if they so request. To request this information, you must submit your request in writing to The Director of Risk and Regulatory Compliance, Carroll Hospital Center, 200 Memorial Avenue, Westminster, MD 21157. Your request must state a time period which may not be longer than six years. Your request should indicate in what form you want the accounting (for example, on paper or electronically). The first accounting you request within a 12-month period will be free. For additional accountings, we may charge you for the costs of providing the accounting. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations as provided in 45 C.F.R. §164.522. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are required to grant your request to restrict or limit our uses or disclosures of medical information about you for payment and/or health care operations if such medical information relates only to a health care item or service for which you paid us in full, out-of-pocket. In all other circumstances, we are not required to agree to your request. If we are required to grant your request, or if we agree to do so, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must either (1) fill out the appropriate form at the time of registration or (2) make your request in writing to The Director of Risk and Regulatory Compliance, Carroll Hospital Center, 200 Memorial Avenue, Westminster, MD 21157. 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, for example, disclosures to your spouse.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location as provided in 45 C.F.R. §164.522. 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 The Director of Risk and Regulatory Compliance, Carroll Hospital Center, 200 Memorial Avenue, Westminster, MD 21157. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how 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. You may ask us to give you a copy of this notice at any time. You may print this document off of our website, download the corresponding PDF of our Privacy Notice/HIPAA brochure or contact The Director of Risk and Regulatory Compliance, Carroll Hospital Center, 200 Memorial Avenue, Westminster, MD 21157 to receive a brochure mailed to your home. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

Changes to this Notice

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the hospital. The notice contains, on the first page, the effective date. In addition, each time you register at or are admitted to the hospital for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.

Complaints and Contact Information

If you have any questions about this notice or wish to request further information, contact The Director of Risk and Regulatory Compliance listed below. If you believe your privacy rights have been violated, you may file a complaint with the hospital or with the Secretary of the Department of Health and Human Services. To file a complaint with the hospital, contact The Director of Risk and Regulatory Compliance. All complaints must be submitted in writing. You will not be retaliated against for filing a complaint.

The Director of Risk and Regulatory Compliance
Carroll Hospital Center, Inc.
200 Memorial Avenue, Westminster, MD 21157
Telephone: (410) 871-6600