Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED, DISCLOSED AND SAFEGUARDED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. INTRODUCTION

The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your protected health information is used. “HIPAA” provides penalties for covered entities that misuse personal health information. This is effective as of April 14, 2003 and we are required by law to abide by the terms of the Notice of Privacy Practices currently in effect. As required by “HIPAA,” we have prepared this explanation of how we are required to maintain the privacy of your protected health information and how we may use and disclose your health information.

II. WHO IS SUBJECT TO THIS NOTICE

Megan Dankovich, M.D., PLLC

III. OUR RESPONSIBILITY

The confidentiality of your personal health information is very important to us. Your health information includes records that we create and obtain when we provide you care, such as a record of your symptoms, examination and test results, diagnoses, treatments and referrals for further care. It also includes bills, insurance claims, or other information that we maintain related to your care.

This notice describes how we handle your health information and your rights regarding this information. Generally speaking, we are required to:

- Maintain the privacy of your health information as required by law;

- Provide you with this Notice of our duties and privacy practices regarding the health information about you that we collect and maintain;

- Follow the terms of our Notice currently in effect.

IV. CONTACT INFORMATION

After reviewing this Notice, if you need further information or want to contact us for any reason regarding the handling of your health information, please direct any communications to the privacy officer.

V. USES AND DISCLOSURES OF INFORMATION

Under federal law, we are permitted to use and disclose personal health information without authorization for treatment, payment, and health care operations. However, the American Psychiatric Association’s Principles of Medical Ethics or state law may require us to obtain your express consent before we make certain disclosures of your personal health information. Participants in this organized health care arrangement also share health information with each other, as necessary to carry out treatment, payment, or health care operation relating to the organized health care arrangement.

VI. OTHER USES AND DISCLOSURES

Abuse, Neglect, or Domestic Violence

As required or permitted by law, we may disclose health information about you to a state or federal agency to report suspected abuse, neglect, or domestic violence. If such a report is optional, we will use our professional judgment in deciding whether or not to make such a report. If feasible, we will inform you promptly that we have made such a disclosure.

Business Associates

We may share health information about you with business associates who are performing services on our behalf. For example, we may contract with a company to service and maintain our computer systems, or to do our billing. Our business associates are obligated to safeguard your health information. We will share with our business associates only the minimum amount of personal health information necessary for them to assist us.

Communications with Family and Friends

We may disclose information about you to persons who are involved in your care or payment for your care, such as family members, relatives, or close personal friends. Any such disclosure will be limited to information directly related to the person’s involvement in your care.

If you are available, we will provide you an opportunity to object before disclosing any such information. If you are unavailable because, for example, you are incapacitated or because of some other emergency circumstance, we will use our professional judgment to determine what is in your best interest regarding any such disclosure.

Food and Drug Administration (FDA)

We may disclose health information about you to the FDA, or to an entity regulated by the FDA, in order, for example, to report an adverse event or a defect related to a drug or medical device.

Health Oversight

We may disclose health information about you for oversight activities authorized by law or to an authorized health oversight agency to facilitate auditing, inspection, or investigation related to our provision of health care, or to the health care system.

Judicial or Administrative Proceedings

We may disclose health information about you in the course of a judicial or administrative proceeding, in accordance with our legal obligations.

Law Enforcement

We may disclose health information about you to a law enforcement official for certain law enforcement purposes. Such disclosure will only occur when required by law.

Minors

If you are an un-emancipated minor under Maryland, District of Columbia or Virginia law, there may be circumstances in which we disclose health information about you to a parent, guardian, or other person acting in loco parentis, in accordance with our legal and ethical responsibilities.

Notification

We may notify a family member, your personal representative, or other person responsible for your care, of your location, general condition, or death.

If you are available, we will provide you an opportunity to object before disclosing any such information. If you unavailable because, for example, you are incapacitated or because of some other emergency circumstance, we will use our professional judgment to determine what is in your best interest regarding any such disclosure.

Parents

If you are a parent of an un-emancipated minor, and are acting as the minor’s personal representative, we may disclose health information about your child to you under certain circumstances. For example, if we are legally required to obtain your consent as your child’s personal representative in order for your child to receive care from us, we may disclose health information about your child to you.

In some circumstances, we may not disclose health information about an un-emancipated minor to you. For example, if your child is legally authorized to consent to treatment (without separate consent from you), consents to such treatment, and does not request that you be treated as his or her personal representative, we may not disclose health information about your child to you without your child’s written authorization.

Personal Representative

If you are an emancipated minor, we may disclose health information about you to a personal representative authorized to act on your behalf in making decisions about your health care.

Public Health Activities

As required or permitted by law, we may disclose health information about you to a public health authority, for example, to report disease, injury, or vital events such as death.

Public Safety

Consistent with our legal and ethical obligations, we may disclose health information about you based on a good faith determination that such disclosure is necessary to prevent a serious and imminent threat to the public.

Required by Law

We may disclose health information about you as required by federal, state, or other applicable law.

Research

We may disclose health information about you for research purposes in accordance with our legal obligations. For example, we may disclose health information without a written authorization if an Institutional Review Board (IRB) or authorized privacy board has reviewed the research project and determined that the information is necessary for the research and will be

adequately safeguarded.

Specialized Government Functions

We may disclose health information about you for certain specialized government functions, as authorized by law. Among these functions are the following: military command; determination of veterans’ benefits; national security and intelligence activities; protection of the President and other officials; and the health, safety, and security of correctional institutions.

Workers’ Compensation

We may disclose health information about you for purposes related to workers’ compensation, as required and authorized by law.

VII. YOUR HEALTH INFORMATION RIGHTS

Under the law, you have certain rights regarding the health information that we collect and maintain about you. This includes the right to:

-Request that we restrict certain uses and disclosures of your health information; we are not, however, required to agree to a requested restriction.

-Request that we communicate with you by alternative means, such as making records available for pick-up, or mailing them to you at an alternative address, such as a P.O. Box. We will accommodate reasonable requests for such confidential communications.

-Request to review, or to receive a copy of, the health information about you that is maintained in our files and the files of our business associates (if applicable). If we are unable to satisfy your request, we will tell you in writing the reason for the denial and your right, if any, to request a review of the decision.

-Request that we amend the health information about you that is maintained in our files and the files of our business associates (if applicable). Your request must explain why you believe our records about you are incorrect, or otherwise require amendment. If we are unable to satisfy your request, we will tell you in writing the reason for the denial and tell you how you may contest the decision, including your right to submit a statement (of reasonable length) disagreeing with the decision. This statement will be added to your records.

-Request a list of our disclosures of your health information. This list, known as an “accounting” of disclosures, will not necessarily include certain disclosures, such as those made for treatment, payment, or health care operations. We will provide you the accounting free of charge, however if you request more than one accounting in any 12 month period, we may impose a reasonable, cost-based fee for any subsequent request. Your request should indicate the period of time in which you are interested (for example, “from May 1, 2003 to June 1, 2003”). We will be unable to provide you an accounting for any disclosures made before April 14, 2003 or for a period longer than six years.

-Request a paper copy of this Notice.

In order to exercise any of your rights described above, you must submit your request in writing to our contact person (see section IV above for information). If you have questions about your rights, please speak with our contact person, available in person or by phone, during office hours.

VIII. TO REQUEST INFORMATION OR FILE A COMPLAINT

If you believe your privacy rights have been violated, you may file a written complaint by mailing it or delivering it to our contact person (see section IV above). You may also complain to the Secretary of Health and Human Services (HHS) by writing to Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C. 20201; by calling 1-(800)368-1019; or by sending an email to OCRprivacy@hhs.gov. We cannot, and will not, make you waive your right to file a complaint as a condition of receiving care from us, or penalize you for filing a complaint with HHS.

IX. REVISIONS TO THIS NOTICE

We reserve the right to amend the terms of this Notice. If this Notice is revised, the amended terms shall apply to all health information that we maintain, including information about you collected or obtained before the effective date of the revised Notice. If the revisions reflect a material change to the use and disclosure of your information, your rights regarding such information, our legal duties, or other privacy practices described in the Notice, we will promptly distribute the revised Notice, post it in the waiting area of our office, and make copies available to our patients and others.

X. EFFECTIVE DATE

January 1, 2010

Notice of Privacy Practices

PATIENT ACKNOWLEDGEMENT

Patient Name: ______________________

DOB:____________

By signing my name, I acknowledge that I have received a copy of the Notice of Privacy Practices of Megan Dankovich, M.D., PLLC, effective January 1, 2010.

Signature (patient or authorized representative): _______________________________

Date: ________________

Relationship/Authority (if signed by authorized representative): ____________________