THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Effective date: [Month DD, 2026]
This Notice applies to [Baltimore Healthcare and Wellness LLC, d/b/a BHW Medical Group, and its affiliated practices including BHW Addiction Management] (“we,” “us”). We are required by law to maintain the privacy of your protected health information (PHI), to give you this Notice of our legal duties and privacy practices, and to follow the terms of the Notice currently in effect.
How we may use and disclose your health information
Treatment
We use and disclose your PHI to provide, coordinate, and manage your care — for example, sharing information with other providers, specialists, labs, or facilities involved in your treatment.
Payment
We use and disclose your PHI to bill and obtain payment — for example, verifying insurance eligibility, submitting claims, and working with your health plan and our clearinghouse and billing service providers.
Health care operations
We use and disclose your PHI for operations such as quality improvement, care coordination, training, and business management.
Other uses and disclosures permitted or required by law (without your authorization)
Subject to applicable limits, we may use or disclose PHI for: appointment reminders and treatment alternatives; individuals involved in your care (with your agreement or as allowed); public-health activities; reporting abuse, neglect, or domestic violence; health-oversight activities; judicial and administrative proceedings; law enforcement; coroners, medical examiners, and funeral directors; organ donation; research (under approved conditions); to avert a serious threat to health or safety; specialized government functions; and workers’ compensation.
Extra-protected information. Some information has stronger protections and generally requires your specific written consent to disclose:
Substance use disorder (SUD) records from our addiction-management services are protected under federal law 42 CFR Part 2 and cannot be redisclosed without your written consent except in narrow circumstances.
Mental / behavioral health records and psychotherapy notes, HIV/AIDS, and genetic information receive heightened protection under federal and [Maryland] law.
[Confirm the exact Part 2 and Maryland provisions with counsel.]
Uses and disclosures that require your written authorization
Most uses and disclosures of psychotherapy notes, uses for marketing, and any sale of PHI require your written authorization. Other uses not described in this Notice will be made only with your authorization. You may revoke an authorization in writing at any time, except to the extent we have already acted on it.
Your rights regarding your health information
Access: inspect and get a copy of your PHI (we may charge a reasonable cost-based fee).
Amend: request a correction to PHI you believe is incorrect or incomplete.
Accounting of disclosures: request a list of certain disclosures we made.
Restrictions: request limits on uses/disclosures. If you pay out of pocket in full for a service, you may request that we not disclose that information to your health plan.
Confidential communications: ask us to contact you a certain way or at a certain location.
Paper copy: receive a paper copy of this Notice on request, even if you agreed to receive it electronically.
Breach notification: be notified if there is a breach of your unsecured PHI.
To exercise any right, contact our Privacy Officer below.
Our responsibilities
We are required to maintain the privacy and security of your PHI.
We will notify you promptly if a breach occurs that may have compromised your information.
We must follow the duties and practices 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.
Changes to this Notice
We may change this Notice, and the changes will apply to all information we have about you. The new Notice will be available on request, on our website, and posted in our office.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer, or with the U.S. Department of Health and Human Services, Office for Civil Rights (200 Independence Avenue SW, Washington, D.C. 20201; 1-877-696-6775; hhs.gov/ocr). We will not retaliate against you for filing a complaint.
Contact — Privacy Officer
BHW Medical Group — Privacy Officer [2300 Garrison Blvd, Ste 100A, Baltimore, MD 21216] [privacy@bhwmedical.org] · [(443) 762-5343]