This notice describes how your medical information may be used and disclosed (provided to others) and how you can gain access to this information. Please review this notice carefully.
As a patient of Ma’am Exams you have the right to know how your private, confidential healthcare and personal information is being protected.
Under the law you have the right (with certain limitations) to:
– Inspect and request copies of your records. Ma’am Exams may charge a reasonable fee for record copies. If for any reason your request to inspect or receive copies of your health information is denied we will inform you or the reason.
– Request that your healthcare provider append information to your medical record.
– Receive a notice of your privacy rights by your health plan upon enrollment and when privacy practices are amended.
Ma’am Exams is required, under specific circumstances, to use or disclose your protected health information without your written authorization. Examples include:
– Public Health activities; judicial & administrative proceedings; correctional institutions & other law enforcement situations
– Disclosure regarding victims of abuse neglect, or domestic violence; health oversight activities.
– Law enforcement; military & veteran activities
– Government programs providing public benefits & workers compensation
– Coroners, Medical Examiners and Funeral Directors
Use of Health Information
Ma’am Exams may use your protected health information to provide you with healthcare services. Ma’am Exams and entities such as health plans may use your health information for the following purposes:
Your doctor may consult with other healthcare practitioners and clinical/laboratory specialists while working on patient cases and treatment plans. These conversations and transfers of information by phone, in person, by fax or email are confidential and names are not used unless necessary and consent is provided either verbally or in writing.
– Health Care Operations
Your doctor may use or disclose, as needed, your protected health information in order to support business activities of our practice. These activities include, but are not limited to: quality assessment; training of medical students and staff; licensing and conducting or arranging for other business activities.
– Records Released
Your confidential healthcare information is private and cannot be copied and shared with anyone else without your written, signed consent. In some cases, if time does not permit, your verbal approval may be accepted. Releasing records is done by photocopy and is most often mailed. It is sent to whom you requested it for and is accompanied by a Confidential Patient Information Cover Sheet. On occasions when faxing of chart notes is required, a Confidential Healthcare Enclosed Fax Cover Sheet accompanies them.
The notes that are taken during appointments are secured by each individual practitioner of Ma’am Exams through secure Electronic Medical Record (EMR) services. Access to Personal Health Information is limited to healthcare practitioners and employees of Ma’am Exams.
Should your doctor or employees of the clinic see you socially, by coincidence or intent, we will not acknowledge how we are acquainted unless you infer consent through introduction, etc. It is your doctor’s preference to discuss your health in the office setting only to protect your privacy and to ensure that your personal health information is kept in your chart.
I have read and understand my right to privacy, as stated above, and agree to have the Ma’am Exams maintain my medical information in accordance with it’s policies and agree to inform the clinic of any special arrangements I need in pertaining to this issue.
Definitions and Penalties to Comply
Protected Healthcare Information is any information, whether oral or recorded, in any form or medium that: 1) is created or received by a healthcare provider, health plan, public health authority, employer life insurer, school or university or healthcare clearing house in the normal course of business, and 2) relates to the past, present or future payment or the provision of healthcare to an individual. This information may reside in any medium: tape, fax, email, digital voice.
For more information on HIPAA privacy requirements, HIPAA electronic transactions and code sets regulations and the proposed
HIPAA security rules, please visit ACOG’s web site, www.acog.org, or call (202) 863-2584.