Patient Privacy

Notice of Privacy Practices

The Notice of Privacy Practices outlines Your Rights and Our Responsibilities as required under the Health Insurance Portability & Accountability Act (HIPAA).  You may request and receive a paper copy of our Notice of Privacy Practices or click here for an electronic copy which you may print for your records.


Pavilion Pediatrics at Green Spring Station, P.A.
10755 Falls Road, Suite 260
Lutherville, MD  21093
Linda Colussi, Practice Administrator


Your Information

Your Rights

Our Responsibilities

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Please review this information carefully.


Your Rights

When it comes to your health information, you have certain rights.  This section explains your rights and some of our responsibilities to help you. 


Get an electronic or paper copy of your medical record.

  • You can ask to see or get an electronic or paper copy of your or your minor child’s medical record and other health information we have about you.
  • We will provide a copy or a summary of your health information, usually within 28 business days of your request, as per Maryland State Law.
  • There is a fee for providing your records to you and is charged as per State Law.

Ask us to correct your medical record.

  • You can ask us to correct health information about you or your minor child that you think is incorrect or incomplete.
  • We may say “no” to your request, but will tell you why, in writing, within 60 days.

Request confidential communication.

  • You can ask us to contact you in a specific way (such as mobile, home or office phones, or via email) or to send mail to a different address.
  • We will say “yes” to all reasonable requests.

Ask us to limit what we use or share.

  • You can ask us not to use or share certain health information for treatment, payment, or our operations.
  • We are not required to agree to your request, and we may say “no” if it would affect your care.
  • If you pay for a service or supply item out of pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless the law requires we share that information.


Get a list of those with whom we have shared information.

  • You can ask for a list of the times we’ve shared your or your minor child’s health information for the past 6 years, who we shared it with and why.
  • We will include all of the disclosures except for those about treatment, payment and healthcare operations, and certain other disclosures (such as any you ask us to make).  We will provide one list a year for free.  There is a reasonable fee for any additional lists requested within 12 months.

Get a copy of this Privacy Notice.

  • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.  We will provide you with a paper copy promptly. Patient Privacy Form

Choose someone to act for you.

  • If you have given someone medical power of attorney over you or your minor child, or if someone is your or your minor child’s legal guardian, that person can exercise your right and make choices about your or your minor child’s 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 your rights are violated.

  • You can complain if you feel we have violated your rights by contacting us using the information on page 1.
  • You can file a complaint with the US Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Ave. S.W., Washington, DC  20201, calling 1-877-696-6775, or visiting
  • We will not retaliate against you for filing a complaint.


Your Choices

For certain health information, you can tell us your choices about what we share.  If you have a clear preference for how we share your information in the situations noted below, tell us what you want and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

  • Share information with your family, close friends, or others involved in your or your minor child’s care.
  • Share information in a disaster relief situation.
  • Include your information in a hospital directory.
  • Contact you for fund raising efforts.
  • If you are not able to tell us your preference, for example, you are unconscious, we may go ahead and share your information if we believe it is in your best interest.  We may also share your information when needed to lessen a serious and imminent threat to health or safety.


In these cases we never share your or your minor child’s information unless you give us written permission:

  • Marketing purposes.
  • Sale of your information.
  • Most sharing of psychotherapy notes.
  • Other uses and disclosures not described in this Notice of Privacy Practices.

In the cases of Fundraising:

  • We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we typically use or share your health information?  We typically use or share your health information in the following ways.

Treat you or your minor child.

  • We can use your health information and share it with other professionals who are treating you or your minor child, such as:
    • Physician/non physician providers
    • Medical Facilities
    • Laboratories
    • School Health Departments
    • School/Camp Nurse
    • Pharmacies

Run our Practice.

  • We can use and share your or your minor child health information to run our Practice, improve your or your minor child’s care, and contact you when necessary.  For example:  we use health information about you or your minor child to manage your or your minor child’s treatment and services.

Bill for your services.

  • We can use and share your or your minor child’s health information to bill and get payment from health plans or other entities.  For example:  we give information about you or your minor child to your health insurance plan so it will pay for your services.

How else can we use or share your or your minor child’s health information?

We are allowed or required to share information in other ways-usually in ways that contribute to the public good, such as public health and research.  We have to meet many conditions in the law before we can share your information for these purposes.  For more information see: .

Help with public health and safety issues.

  • We can share health information about you or your minor child for certain situations such as:
    • Preventing disease
    • Helping with product recalls
    • Reporting adverse reactions to medications
    • Reporting suspected abuse, neglect, or domestic violence
    • Preventing or reducing a serious threat to anyone’s health or safety


Do research.

  • We can use or share your or your minor child’s information for health research.


Comply with the Law.

  • We will share information about you or your minor child if State or Federal Laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.

Respond to organ and tissue donation requests.

  • We can share health information about you or your minor child with organ procurement organizations.

Work with a medical examiner or funeral director.

  • We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address worker’s compensation, law enforcement, and other government requests.

  • We can use or share health information about you or your minor child for
    • Worker’s compensation claims
    • Law enforcement purposes or with a law enforcement official
    • Activities authorized by law with health oversight agencies
    • Special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions.

  • We can share health information about you or your minor child in response to a court or administrative order, or in response to a subpoena.


  • For divorced or separated parents: each parent has equal rights to the health information about their child(ren), unless there is a court order otherwise stating who does and who does not have rights and is known to us or unless it is a type of treatment or service where parental rights are restricted.
  • We can release your child’s medical information to a nanny, friend or family member involved in your child’s medical care. For example:  a nanny, relative, or friend who is asked by, you, the parent or guardian to accompany your child to our office for care.  Written authorization from, you, the parent or guardian is required for someone else to accompany your child.


We do not:

  • Create or manage a hospital directory.
  • Perform any fund raising and will not contact you for fund raising efforts.
  • Create or maintain psychotherapy notes.
  • Sell patient information.

Our Responsibilities


  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • 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.  However, you must let us know in writing if you change your mind.


For more information see: .


Changes to the terms of this notice:

We can change the terms of this notice, and the changes will apply to all information we have about you.  The new notice will be available upon request, in our office, and on our website.


Updated June 23, 2016


This Notice of Privacy Practices applies to the following organizations.


We have chosen to participate in the Chesapeake Regional Information System for our Patients (CRISP), a regional health information exchange serving Maryland and D.C.  As permitted by law, your and your minor child’s health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions.  You may “opt out” and disable access to your and/or your minor child’s health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax, or through their website at Public Health reporting and controlled dangerous substances information, as part of the Maryland Prescription Drug Monitoring Program (PDMP), will still be available to providers.




Linda Colussi, Practice Administrator, Privacy Officer          410-583-7151                      [email protected]