I. This notice describes how medical information about you may be disclosed and how you can get access to this information. Please review it carefully.

Because we are a medical care provider that does not engage in any transactions that invoke coverage of the HIPAA Privacy Act, the privacy practices and terms described in this notice are voluntarily undertaken. We reserve the right to modify our privacy practices and this notice at any time.

Protected Health Information, or PHI is: Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for health care. We will extend certain protection to your PHI. This Notice explains how, when and why we may use or disclose your PHI. Except in specified circumstances, we will only use or disclose the minimum necessary PHI to accomplish the intended purpose of the use or disclosure.

II.  Our Responsibilities: Safeguarding Your Protected Health Information

We will: Maintain the privacy and security of your protected health information; Let you know promptly if a breach occurs that may have compromised the privacy or security of your information; Follow the duties and privacy practices described in this notice and give you a copy, if requested.

We will not: Use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

III.  How We May Use and Disclose Your Protected Health Information

We use and disclose PHI primarily for purposes of treatment or our health care operations. For uses beyond that, we will ordinarily obtain your written authorization. The following offers more description and some examples of the potential uses and disclosures of your PHI:

Uses and Disclosures Relating to Treatment or Health Care Operations. We may disclose your PHI to doctors, nurses and other health care personnel who are involved in providing your health care. Your PHI may be shared with outside entities performing ancillary services to your treatment. Also, we may use and/or disclose your PHI as may be reasonably necessary in the course of operating our medical clinic. We may also send or communicate appointment reminders but subject to our normal confidentiality policies and any special instructions that you have given.

Uses and Disclosures for Which Special Authorization Will Be Sought. For uses beyond treatment and operations purposes, we will ordinarily seek to obtain your authorization before disclosing your PHI. However, disclosure of your PHI may be made without your consent or authorization when required by law, when required for public health reasons, when necessary to avert a threat of harm to you or a third person, in response to a lawsuit, for conducting research, or when other circumstances may require or reasonably warrant such disclosure.

IV.  Your rights

Inspect and copy your PHI: Unless your access is restricted for clear and documented treatment reasons, you will be permitted to inspect your protected health information upon written request. We will respond to your request within 30 days. If we deny your request for access, we will give you written reasons for the denial within 60 days. If you want copies of your PHI, we will make reasonable efforts to accommodate any such request. You may designate selected portions of your PHI for copying. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record: If you believe that there is a mistake or missing information in our record of your PHI, you may request in writing that we correct or add to the record. We will respond within 60 days of receiving your request. Any denial will state the reasons for the denial. If we approve the request for amendment, we will change the PHI and so inform you. We will also inform any others who have a need to know about such changes.

Choose how we contact you: You may ask that we send you information at an alternative address or by alternative means. We will agree to your request so long as it is reasonably easy for us to do so.

Request restrictions on uses/disclosures: You may ask that we limit how we use or disclose your PHI. We will consider your request, but we are not legally bound to agree to the restriction. To the extent that we do agree to such restrictions, we will abide by such restrictions except in emergency situations. We cannot agree to limit uses/disclosures that are required by law.

Find out what disclosures have been made: You may request for us to provide you with a list of all disclosures of your PHI which we have made except for such disclosures as have been made in connection with your treatment, our health care operations, or as specifically required by law. We will respond to your request within 60 days of receiving it.

Copy of this notice: you may receive a paper copy of this notice upon request.

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. We will make sure the person has this authority and can act for you before we take any action.

File a complaint: If you feel we have violated your rights, you may register a complaint by contacting us using the information below. You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W. Washington, D.C. 20201, calling 877-696-6775, or visiting

Your choices: for certain health information, you may tell us your choices about what we share. You may tell us to: share information with your selected family, friends, or others involved in your care; share information in a disaster relief situation.

V.  Contact Person: If you have any questions or concerns about our privacy practices, please contact:

Sandy Christiansen, M.D. Medical Director
Care Net Pregnancy Center
707 N. Market St
Frederick, MD 21701

 VI.  Acknowledgement: the undersigned certifies that they have received this form and that they are the patient/patient’s legal guardian.