Patient Privacy Policy







Uses and Disclosures


Treatment. Your health information may be used by staff members or disclosed

to other health care professionals for the purpose of evaluating your

health, diagnosing medical conditions, and providing treatment. For example,

results of laboratory tests and procedures will be available in your medical

record to all health professionals who may provide treatment or who may

be consulted by staff members.


Payment. Your health information may be used to seek payment from your

health plan, from other sources of coverage such as an automobile insurer, or

from credit card companies that you may use to pay for services. For example,

your health plan may request and receive information on dates of service,

the services provided, and the medical condition being treated.


Health care operations. Your health information may be used as necessary

to support the day-to-day activities and management of Cumberland Valley Surgery Center.

For example, information on the services you received may be used to

support budgeting and financial reporting, and activities to evaluate and promote


Law enforcement. Your health information may be disclosed to law enforcement

agencies to support government audits and inspections, to facilitate

law-enforcement investigations, and to comply with government-mandated


Public health reporting. Your health information may be disclosed to public

health agencies as required by law. For example, we are required to report

certain communicable diseases to the state’s public health department.


Other uses and disclosures require your authorization. Disclosure of your

health information or its use for any purpose other than those listed above

requires your specific written authorization. If you change your mind after

authorizing a use or disclosure of your information you may submit a written

revocation of the authorization. However, your decision to revoke the authorization

will not affect or undo any use or disclosure of information that

occurred before you notified us of your decision to revoke your authorization.

Additional Uses of Information


Appointment reminders. Your health information will be used by our staff

to send you appointment reminders.



Information about treatments. Your health information may be used to

send you information that you may find interesting on the treatment and

management of your medical condition. We may also send you information

describing other health-related products and services that we believe may

interest you.


Fundraising. Unless you request us not to, we will use your name and

address to support our fundraising efforts. If you do not want to participate

in fundraising efforts, please check off the following box.

❑ Please do not use my information for fundraising purposes.

Individual Rights

You have certain rights under the federal privacy standards. These include:

◆ The right to request restrictions on the use and disclosure of your

protected health information

◆ The right to receive confidential communications concerning your

medical condition and treatment

◆ The right to inspect and copy your protected health information

◆ The right to amend or submit corrections to your protected health


◆ The right to receive an accounting of how and to whom your protected

health information has been disclosed

◆ The right to receive a printed copy of this notice


Cumberland Valley Surgery Center Duties

We are required by law to maintain the privacy of your protected health

information and to provide you with this “Notice of Privacy Practices.”


We also are required to abide by the privacy policies and practices that are

outlined in this notice.


Right to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy

policies and practices. These changes in our policies and practices may be

required by changes in federal and state laws and regulations. Upon request,

we will provide you with the most recently revised notice on any office visit.

The revised policies and practices will be applied to all protected health

information we maintain.


Requests to Inspect Protected Health Information

You may generally inspect or copy the protected health information that we

maintain. As permitted by federal regulation, we require that requests to

inspect or copy protected health information be submitted in writing. You

may obtain a form to request access to your records by contacting

Medical Records staff member or the Administrator. Your request will be reviewed

and will generally be approved unless there are legal or medical

reasons to deny the request.






If you would like to submit a comment or complaint about our privacy

practices, you can do so by sending a letter outlining your concerns to:

Elaine Tiznado


Cumberland Valley Surgery Center

1110 Professional Court

Hagerstown MD 21742


If you believe that your privacy rights have been violated, you should call the

matter to our attention by sending a letter describing the cause of your concern

to the same address.

You will not be penalized or otherwise retaliated against for filing a complaint.


Contact Person

The name and address of the person you may contact for further information

concerning our privacy practices is:

Elaine Tiznado


Cumberland Valley Surgery Center

1110 Professional Court

Hagerstown MD 21740   240-420-5559

Fax: 240-420-3786

1110 Professional Ct.
Hagerstown, MD 21740

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