HIPAA Policy

Your Privacy Rights


Baltimore Ketamine Clinic is required by law to keep your health information safe. This information may include the following:

  • notes from your doctor, teacher, or other health care provider
  • medical history
  • test results
  • treatment notes
  • insurance information

A government rule requires that you get a copy of this privacy notice. This rule is called the Health Insurance Portability and Accountability Act—or HIPAA for short. We will ask you to sign a paper saying that you have been given this notice.

Read this notice at any time to see how your health information can be used and who can see it.

How Your Health Information May be Used or Shared

We may use or share your health information both with and without your permission, depending on the circumstances.

When Your Permission Is Not Needed

We may use or share your health information without your permission for the following reasons:

  • Treatment. We may share information with doctors and other health care providers who care for you. For example, if your doctor orders speech therapy, we will share the results of our treatment with that doctor.
  • Payment. We may use and share information about the treatment you receive with your insurance company or other payer to receive payment for services. This may include sharing important medical information. We may share information to
    • get the insurance company’s permission to start treatment,/li>
    • get permission for more treatment, and/or
    • get paid for the treatment you receive.
  • Health Care Operations. We may use and share your health information to run the clinic and make sure all patients receive good care. For example, we may use your health information to
    • see how well our services are working,
    • see how well our staff is doing,
    • see how we compare to other clinics,
    • improve our services, and
    • help others study health care services.
  • Abuse and Neglect. We may share your health information with government agencies when there is evidence of abuse, neglect, or domestic violence.
  • Appointment Reminders. We will use your information to remind you of upcoming appointments. Reminders may be sent by email, by text message, by phone call or voicemail message. If you do not wish to get reminders, please notify our front desk.
  • As Required by Law. We will share your information when we are told to do so by federal, state, or local law. We will also share information if we are asked by the police or courts.
  • Government Functions. Your information may be shared for national security or military purposes. If you are a veteran, your information may be shared with the U.S. Department of Veterans Affairs.
  • Information About a Person Who Has Died. We may share information with the coroner, the medical examiner, or a funeral director, as needed.
  • Marketing. We may use your information to let you know of other services that might be of interest to you.
  • Public Health Risks. We may report information to public health agencies as required by law. This may be done to help prevent disease, injury, or disability. It may also be done to report medical device safety issues to the Food and Drug Administration and to report diseases and infections.
  • Regulatory Oversight. We may use or share your information to report to agencies overseeing health care. This may include sharing information for audits, licensure, and inspections.
  • Research. We may share your health information with researchers to be included in their research project. Information will be shared only for projects that have been through a special approval process. These projects have rules to protect your privacy, too.
  • Threats to Health and Safety. Your health information may be shared if it is believed that this information will prevent a threat to your or others’ health and safety.
  • Workers’ Compensation. We will share your information with the U.S. Department of Labor’s Office of Workers’ Compensation if your case is being considered as a work-related injury or illness.

When Your Permission Is Needed

You must give us permission to use or share your health information for any situation that is not listed in this notice. You will be asked to sign a form—called an authorization—to allow us to use or share your information. You are allowed to take back this authorization—called revoking authorization—at any time. We will not be able to get the information back that we shared with your permission.

Your Privacy Rights

You have the right to do all of the following:

  • Ask us not to share your information. You can ask us not to use or share your information for treatment, payment, or health care operations. You can also ask us not to share information with people involved in your care, like family members or friends. You must ask for limits in writing. We must share information when required by law. We do not have to agree to what you ask.
  • Ask us to contact you privately. You can ask us to only contact you in a certain way or at a certain place. For example, you may want us to call you but not email. Or you may want us to call you at work and not at home. You must ask us in writing. We will make every effort to comply with your request.
  • Look at and copy your health information. You have the right to see your health information and get a copy of that information. You have a right to see treatment, medical, and billing information. You may not be able to see or copy information put together for a court case, certain lab results, and copyrighted materials, such as test protocols.
  • Ask for changes to your health information. You can ask us to change information that you think is wrong. You can also ask that we add information that is missing. You must ask us in writing and give us a reason for the change. We do not have to make the change.
  • Get a report of how and when your information was used or shared. You can ask us to tell you when your information was shared and who we shared it with. There are some rules about this:
    • You must ask us in writing.
    • You must tell us the dates you are asking about and if you want a paper or electronic copy.
    • You may get information going back 6 years, but it cannot be for earlier than April 14, 2003. This is the date when the government privacy rules took effect.
  • Get a paper copy of this privacy notice. You can get a paper copy of this notice at any time. You can get a copy even if you have already signed the form saying you have seen this notice.
  • File complaints. You can file a complaint with us or with the U.S. government if you think that
    • your information was used or shared in a way that is not allowed,
    • you were not allowed to look at or copy your information, and/or
    • any of your rights were denied.

Who Is Covered by This Notice

The people who must follow the rules in this notice are as follows:

  • all employees working at Baltimore Ketamine Clinic
  • anyone who is allowed to add health information to your file, including students and other staff
  • any volunteers who may help you while you are in this clinic

Changes to the Information in This Notice

We may change this notice at any time. Changes may apply to information that we already have in your file and to any new information. Copies of the new notice will be available from our staff. The notice will have a date on the front page to tell you when it went into effect.


You may file a complaint if you think we did something wrong with your information. You can complain to your regional office of the U.S. Office of Civil Rights. To find out more about filing complaints, go to www.hhs.gov/ocr/privacy/hipaa/complaints/index.html. All complaints must be in writing. You will not get penalized for filing a complaint.


If you have any questions about this notice or your privacy rights, please ask your physician or nurse provider, or contact Ivana Mitic at 410-584-3621 or info@baltimoreketamineclinic.com

This information is provided as a resource for ASHA members. ASHA makes no guarantees about the content. You should review it carefully to ensure that it meets your specific needs, including all relevant state laws that may be more stringent than HIPAA regulations.